Legislation: SB 228 (ACOEM, UR and more)

The 2003 session of the California legislature enacted SB228 which significantly impacts the manner in which medical care is delivered to injured workers. We have provided a highlight of the essential aspects of this law to assist you in providing the best medical care to the injured worker in accordance with the new mandate.

ACOEM Guidelines
The State of California has adopted the American College of Occupational and Environmental Medicine (ACOEM) treatment guidelines as the presumption of correctness with regard to the extent and scope of medical treatment of a work related injury for all dates of injury or dates of service as of March 22, 2004. Medical care rendered to an injured worker must be in accordance with this guideline. The ACOEM guideline is available through information posted on the ACOEM website, http://www.acoem.com.

Utilization Review Process
SB228 further provided that every employer establish a utilization review process, either directly or through its insurer or entity with which it contracts for these services. This utilization review process must:

• be governed by written policies and procedures;
  
• have a Medical Director who holds an unrestricted California medical license;
  
• and allows for a licensed physician only to modify, delay or deny requests for authorization of medical treatment.

The criteria or guidelines used in the review process must be consistent with the ACOEM guidelines, developed from actively practicing physicians, reviewed for accuracy and appropriateness annually and made available upon request to the physician and the public.

As the Utilization Review company for our clients ACOEM guidelines are incorporated into the UR process for treatment and diagnostic requests. For items not covered in the ACOEM guidelines, we utilize other nationally recognized evidence based guidelines. Authorizations will reflect our adherence to these guidelines, and the evidence based material upon which our Utilization Review decision was made.

Outpatient Surgery Center Referrals
The new law has also affected the referral of patients to out surgery centers. It has made it unlawful for a physician to refer a person for outpatient surgery to a center in which the physician or his or her immediate family has a financial interest with the person or the entity that receives the referral. The law further defines financial interest financial in depth. This prohibition does not apply where the referring physician obtains a service preauthorization from the Payor after disclosure of the financial interest. Disclosure of the financial interest alone is not sufficient; there must also be preauthorization from the Payor.

Generic Drug Equivalent
In addition, the new law provides for the generic drug equivalent to be dispensed to injured workers if available unless the prescribing physician provides otherwise in writing.

Payment Timeframe
Payment to a physician who has provided medical treatment to an injured worker is to be received within 45 days of the insurer receiving a billing statement and other documentation.

Physical Therapy/Chiropractic Visits
For dates of injury of January 1, 2004 and subsequent, there is a numerical limitation to twenty four (24) physical therapy and chiropractic treatments for the life of the claim unless additional are authorized in writing by the Payor.

Spinal Surgeries
Requests for spinal surgery will be handled through the Utilization Review process. However, if a spinal surgery request is not certified by the UR company, the may object in writing to the recommendation for the surgery within ten (10) days of receipt of the written request for the surgery. In that event, if the injured worker is represented there is a ten (10) day period for the and attorney representing the injured worker to agree on a California licensed board certified or board eligible Orthopedic surgeon or Neurosurgeon to prepare a second opinion report resolving the disputed surgical recommendation. If no agreement is reached within the 10 day period of time or if the injured worker is not represented by an attorney, an Orthopedic surgeon or Neurosurgeon shall be randomly selected by the Administrative Director of the Division of Workers’ Compensation to prepare a second opinion report resolving the disputed surgical recommendation. This second opinion report shall be prepared and delivered to the Payor, injured worker and if appropriate the attorney representing the injured worker within forty five (45) days of receipt of the original treating physician’s report who requested the spinal surgery. If the disputed surgical procedure is performed prior to completion of the second opinion the Payor is not liable for the medical treatment costs for the disputed surgical procedure whether a lien has been filed or not or for periods of temporary disability resulting from the surgery.

We hope that this will serve as a foundation of knowledge for our physicians to provide quality medical care for injured workers whether part of the HCO or not in accordance with SB 228. The detail of SB228 can be found on the website of the Division of Workers’ Compensation at http://www.dwc.ca.gov