Bill Text: DE HB373 | 2013-2014 | 147th General Assembly | Engrossed
Bill Title: An Act To Amend Titles 18 And 19 Of The Delaware Code Relating To Workers' Compensation Insurance.
Spectrum: Slight Partisan Bill (Democrat 37-23)
Status: (Passed) 2014-07-15 - Signed by Governor [HB373 Detail]
Download: Delaware-2013-HB373-Engrossed.html
SPONSOR: |
Rep. B. Short & Rep. Briggs King, & Sen. Blevins, & Sen. Hocker |
|
Reps. Atkins, Barbieri, Baumbach, Bennett, Blakey, Bolden, Brady, Carson, Dukes, Gray, Heffernan, Hudson, Jaques, J. Johnson, Q. Johnson, Kenton, Kowalko, Longhurst, Miro, Mitchell, Mulrooney, Osienski, Outten, Paradee, Peterman, Potter, Ramone, Schwartzkopf, Scott, D. Short, M. Smith, Smyk, Spiegelman, Viola, Walker, D.E. Williams, K. Williams, Wilson; Sens. Bonini, Bushweller, Cloutier, Ennis, Henry, Lavelle, Lawson, Lopez, McBride, Peterson, Pettyjohn, Poore, Simpson, Sokola, Townsend, Venables |
HOUSE BILL NO. 373 AS AMENDED BY HOUSE AMENDMENT NOS. 1 & 2 |
Section 1.Amend Chapter 26, Title 18 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§2610 Review of insurance filings.
(e) Upon
the filing of any application by a workers' compensation advisory organization
with the Commissioner relating to rates or prospective loss costs, the Commissioner
Workers' Compensation Oversight Panel authorized in Title 19 of the Delaware
Code shall, with the consent of the Attorney General, retain a member of
the Delaware Bar to represent the interests of Delaware workers' compensation
rate-payers during the Commissioner's consideration of the application (the
"ratepayer advocate"). The cost of the ratepayer advocate shall be
borne by the advisory organization. It is the expectation of the General
Assembly that $40,000 should be sufficient to adequately compensate the
ratepayer advocate for his or her services during the course of an application
(including any appeals), and compensation for the ratepayer advocate is limited
to this amount, which may be adjusted by the Attorney General for inflation on
an annual basis.The Department of
Labor shall provide staff support for the Workers' Compensation Oversight Panel
in carrying out this responsibility.
(f) Applications by a workers' compensation advisory organization relating to rates or prospective loss costs shall be subject to the case decision provisions of Title 29, Chapter 101, subchapter III, and the ratepayer advocate shall be considered a party to the case. The Department of Insurance shall promulgate regulations within 60 days to ensure that the ratepayer advocate has adequate time and means to properly participate in the hearing required by Title 29, Chapter 101, subchapter III. The advisory organization may, but need not be, represented by counsel in this proceeding.
(g) The ratepayer advocate shall select an actuary to work with him or her and testify in the rate-setting proceeding outlined in subsections (e) and (f) of this section. The cost of this actuary shall be borne by the advisory organization. It is the expectation of the General Assembly that any other actuaries used by the Department of Insurance during the rate-setting process outlined in subsections (e) and (f) of this section shall be paid for by the Department of Insurance.
Section 2.Amend Chapter 23, Title 19 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§2301E Data Collection Committee.
(a) It is the intent of the General Assembly
that the Insurance Commissioner, and an advisory organization designated pursuant
to Chapter 26 of Title 18, be provided with data enabling them to conduct
studies to evaluate the workers' compensation system in the State of Delaware,
identify systemic cost drivers, provide objective information to guide policy
formulation, and identify carrier-specific cost drivers.
(b) The Insurance Commissioner shall appoint
a Data Collection Committee to advise the Commissioner concerning the adoption
of a standardized data transmission protocol, developed and supported by a
national workers' compensation organization, to facilitate the collection of
data concerning reports of industrial injuries and occupational disease, the
cost of benefits associated with such injuries and diseases, and compliance
with the mandatory workers' compensation insurance requirement, and to ensure
compliance by individual carriers with their responsibilities relating to
medical cost control. The committee shall be chaired by the Insurance
Commissioner or the Commissioner's designee, and shall also include 4 representatives
of insurance carriers, including at least 1 insurance carrier that writes at
least 10% of the total workers' compensation premiums in the State, and 1
insurance carrier that writes less than 5% of the total workers' compensation
premiums in the State, and 2 representatives each from the medical community,
the business community, the legal community, and organizations representing
employees.
(c) The Insurance Commissioner, with the
advice of the Data Collection Committee, shall adopt rules establishing a
standardized data collection protocol, the data elements that will be mandated
for collection, and a schedule for implementation of mandatory data submission
and sanctions for noncompliance.
(d) The Insurance Commissioner, with the
advice of the Data Collection Committee, shall annually report to the Governor
and the General Assembly the progress of data collection efforts and
information obtained from the analysis of the data collected pursuant to this
section.
(e) Data shall be provided to the Data
Collection Committee on at least a quarterly basis, and the committee shall
share the data it collects with the Health Care Advisory Panel created by §
2322A of this title.
(f) The advisory organization shall, on an
annual basis beginning on August 1, 2013, provide the Data Collection Committee
with carrier-specific medical cost data for each workers' compensation carrier
having a market share in Delaware of 3% or greater over the 12 preceding
months. If, after reviewing said data and making necessary inquiries with
individual carriers, the Data Collection Committee determines that there is a
well-founded concern that an individual carrier is not sufficiently
scrutinizing medical payments, the Data Collection Committee may direct the
Insurance Commissioner to conduct a formal examination of a carrier to
determine compliance with applicable laws and regulations regarding medical
reimbursements.
(g) The Department of Insurance may exercise
its authority granted under Title 18 to address legitimate competitive, trade
secret, or health privacy concerns that arise in connection with compliance
with this section, provided that the Department's exercise of this authority
shall not interfere with the Data Collection Committee's ability to fulfill its
statutory obligations.
§2322A Health Care Advisory Panel.
(a) The General Assembly recognizes that issues related to
health care in workers' compensation require the expertise of the medical
community and other health care professionals for resolution. A Health Care
Advisory Panel is hereby established. The purpose of the Health Care Advisory
Panel shall be to carry out the provisions of this chapter, with a diversity of
perspectives, on matters relating to the provision of health care to employees
pursuant to this chapter.
(b) Membership; terms. — The Health Care Advisory Panel shall
consist of 17 members. All members shall be appointed by the Governor by and
with the consent of the Senate. As provided below, a majority of members shall
be health care providers or representatives of providers. Members shall be appointed
for a term of up to 3 years and may be re-appointed. Terms of members shall be
staggered so that less than half of the members' terms expire in any 1 year.
Members shall receive no compensation.
(c) Representation. — The Health Care Advisory Panel shall
include: 1 representative of insurance carriers providing coverage pursuant to
this chapter; 1 representative of employers; 1 representative of employees; 2
attorneys licensed to practice law, 1 who regularly represents employees and 1
who regularly represents employers in matters arising under this chapter; 3
public members; and 9 provider members. A public member: may not be nor may
ever have been certified, licensed, or registered in any health-related field;
may not be the spouse of someone certified, licensed, or registered in any
health-related field; at the time of appointment may not be a member of the
immediate family of someone certified, licensed, or registered in any
health-related field; may not be employed by a company engaged in a directly
health-related business; and may not have a material financial interest in
providing goods or services to persons engaged in the practice of medicine. The
9 provider members appointed to the Health Care Advisory Panel shall include a
diverse group of health care providers (or provider representatives) who are
most representative of those providing medical care to employees pursuant to
this chapter. The provider members shall include representatives nominated by
the following professional societies or associations:
(1)
Four representatives of the Medical Society of Delaware (including 1 in the
field of primary care, 1 in the field of neurosurgery, 1 in the field of
occupational medicine and 1 at large representative);
(2)
One representative of the Delaware Society of Orthopaedic Surgeons;
(3)
One representative of the Delaware Academy of Physical Medicine and
Rehabilitation;
(4)
One representative of the Delaware Healthcare Association;
(5)
One representative of the Delaware Chiropractic Association; and
(6)
One representative of the Delaware Physical Therapy Association.
One
member may represent more than 1 category. In addition to their ability to
represent the perspective of their profession, provider members shall be
selected for their ability to represent the interests of the community at
large. The Department of Labor, Office of Workers' Compensation shall provide
at least 1 nonvoting staff to assist the Panel in its work.
(d) Any person appointed to fill a vacancy on the Health Care
Advisory Panel shall serve for the remainder of the unexpired term of the
former member and shall be eligible for reappointment.
(e) Regular attendance is vital to the purposes of the Health
Care Advisory Panel. Members shall accept the duty and obligation to attend meetings.
Repeated absences shall be grounds for removal from the Panel at the discretion
of the Governor.
(f) A Chair and Vice Chair shall be elected by a majority of
members of the Health Care Advisory Panel for terms of 1 year. The Chair and/or
Vice Chair may be replaced at any time by a majority vote of members of the
Health Care Advisory Panel. The Chair and Vice Chair of the Health Care
Advisory Panel shall set an agenda for each meeting, shall preside at meetings,
and shall forward recommendations, opinions and other communications of the
Health Care Advisory Panel to the Governor and General Assembly.
(g) The Health Care Advisory Panel is authorized to appoint by
majority vote such committees as it may deem appropriate and to define the
powers duties and responsibilities of such committees. Such committees may
include persons who are not regular members of the Health Care Advisory Panel.
(h) Order of business and schedule of meetings. — Meetings of
the Health Care Advisory Panel shall be held at least 4 times annually and
shall be scheduled by the Chair. Agendas for meetings shall be developed by the
Chair and/or Vice-Chair of the Panel. Any member wishing to include an item on
the agenda has the responsibility to draft and present the agenda item to the
Chair for approval and inclusion. An agenda shall be distributed by the Office
of Workers' Compensation to members at least 14 days prior to the next meeting.
Staff from Office of Workers' Compensation shall record all meeting proceedings
and prepare minutes for approval by the Health Care Advisory Panel prior to the
next meeting. The Health Care Advisory Panel is authorized to adopt by majority
vote bylaws and other procedures for meetings not inconsistent with this
chapter. For any matter considered by the Health Care Advisory Panel that does
not have unanimous approval, members shall be authorized to issue minority
reports. Neither the Health Care Advisory Panel nor any committee thereof shall
be subject to the provisions of Chapter 100 of Title 29.
(i) Quorum and voting. — Administrative decisions, including
the election of officers, recommendations to remove a member, or the adoption
or amendment of bylaws, shall be effective upon approval by a majority of all
members of the Health Care Advisory Panel. All other matters shall be subject
to approval for by a majority of persons present at a duly constituted meeting
consisting of at least a quorum of members. A quorum of at least 9 members, at
least 5 of whom shall be provider representatives referred to in subsection (c)
of this section above.
§2322A Workers' Compensation Oversight Panel
(a) Membership; terms. — The Workers' Compensation Oversight Panel shall consist of 24 members.Members serving by virtue of position may appoint a designee to serve at their pleasure in their stead. The Governor shall appoint the 13 non provider members who are not serving by virtue of position. The Governor appointed members shall be appointed for a term up to 3 years to allow that no more than 5 Governor appointed members' terms shall expire in any year. The provider members shall be appointed by the appointing authority and for a term of 3 years.
(b) Representation. — The Workers' Compensation Oversight Panel shall include: 2 representatives of insurance carriers providing coverage pursuant to this chapter; 2 representatives of employers; 2 representatives of employees; 2 attorneys licensed to practice law, 1 who regularly represents employees and 1 who regularly represents employers in matters arising under this chapter; the Secretary of Labor; the Insurance Commissioner; 1 representative of Delaware insurance agents; 4 public members; and 9 provider members. A public member: may not be nor may ever have been certified, licensed, or registered in any health-related field; may not be the spouse of someone certified, licensed, or registered in any health-related field; at the time of appointment may not be a member of the immediate family of someone certified, licensed, or registered in any health-related field; may not be employed by a company engaged in a directly health-related business; and may not have a material financial interest in providing goods or services to persons engaged in the practice of medicine. The 9 provider members appointed to the Workers' Compensation Oversight Panel shall include a diverse group of health care providers (or provider representatives) who are most representative of those providing medical care to employees pursuant to this chapter. The provider members shall consist of the following:
(1) the President of the Medical Society of Delaware shall appoint 4 Delaware licensed physicians which shall include 1 in the field of primary care, 1 in the field of neurosurgery, and 2 at large representatives;
(2) the President of the Delaware Society of Orthopaedic Surgeons shall appoint a Delaware licensed Orthopedic surgeon;
(3) the President of the Delaware Academy of Physical Medicine and Rehabilitation shall appoint one representative;
(4) the President of the Delaware Healthcare Association shall appoint one representative;
(5) the President of the Delaware Chiropractic Association shall appoint a Delaware licensed Chiropractor; and
(6) the President of the Delaware Physical Therapy Association shall appoint a Delaware licensed Physical Therapist.
In addition to their ability to represent the perspective of their profession, provider members shall be selected for their ability to represent the interests of the community at large. The Department of Labor, Office of Workers' Compensation shall provide staff support to the Panel.
(c) Members of the former Health Care Advisory Panel shall, absent contrary action by the Governor, serve the remainder of their terms for which they were appointed to the Health Care Advisory Panel as members of the Workers Compensation Oversight Panel.
(d) A Chair and Vice Chair shall be selected by the Governor. The Chair and Vice Chair of the Workers' Compensation Oversight Panel shall set an agenda for each meeting, shall preside at meetings, and shall forward recommendations, opinions and other communications of the Panel to the Governor and General Assembly.
(e)Data Collection.It is the intent of the General Assembly that, among its other duties, the Workers' Compensation Oversight Panel be provided with data enabling it to conduct studies to evaluate the workers' compensation system in the State of Delaware, identify systemic cost drivers, provide objective information to guide policy formulation and identify carrier specific cost drivers.To that end, the Panel is authorized to collect data concerning reports of industrial injuries and occupational disease, the cost of benefits associated with such injuries and diseases, and compliance with the mandatory workers' compensation insurance requirement.The Panel is also charged with ensuring compliance by individual carriers with their responsibilities relating to medical cost control.On at least a quarterly basis, the Insurance Commissioner shall collect and provide to the Panel data sufficient for the Panel to carry out the duties described in this subsection.In addition, the Panel or its designee shall have the authority to demand directly from any person or entity providing health care services under this Chapter data sufficient for the Panel to carry out the duties described in this subsection.The advisory organization designated pursuant to 18 Del.C. §2607 shall also on an annual basis provide the Panel with carrier-specific medical cost data for each workers' compensation carrier having a market share in Delaware of 1% or greater over the 12 preceding months. If, after reviewing said data and making necessary inquiries with individual carriers, the Panel determines that there is a well-founded concern that an individual carrier is not sufficiently scrutinizing medical payments, the Panel may direct the Insurance Commissioner to conduct a formal examination of a carrier to determine compliance with applicable laws and regulations regarding medical reimbursements.The Department of Insurance may exercise its authority granted under Title 18 to address legitimate competitive, trade secret, or health privacy concerns that arise in connection with its responsibilities under this section, provided that the Department's exercise of this authority shall not interfere with the Panel's ability to fulfill its statutory obligations.The Secretary of Labor shall have authority to address legitimate competitive, trade secret, or health privacy concerns that arise in connection with the Panel's collection of data directly from persons or entities providing health care services under this Chapter, provided that the Secretary's exercise of this authority shall not interfere with the Panel's ability to fulfill its statutory obligations.
§2322B Procedures and requirements for promulgation of health care
payment system.
The health care payment system developed pursuant to this section
shall be subject to the following procedures and requirements:
(1) The intent of the General Assembly in authorizing a health
care payment system is not to establish a "push down" system, but is
instead to establish a system that eliminates outlier charges and streamlines
payments by creating a presumption of acceptability of charges implemented
through a transparent process, involving relevant interested parties, that
prospectively responds to the cost of maintaining a health care practice,
eliminating cost-shifting among health care service categories and avoiding
institutionalization of upward rate creep.
(2) The health care payment system shall include payment rates,
instructions, guidelines, and payment guides and policies regarding application
of the payment system. When completed, the payment system shall be published on
the Internet at no charge to the user via a link from the Office of Workers'
Compensation website at http://odia.delawareworks.com/workers-comp/, or a
successor website. The payment system shall also be made available in written
form at the Office of Workers' Compensation during regular business hours.
(3)a.
The maximum allowable payment for health care treatment and procedures covered
under this chapter shall be the lesser of the health care provider's actual
charges or the fee set by the payment system. The payment system will set fees
at 90% of the seventy-fifth percentile of actual charges within the geozip
where the service or treatment is rendered, utilizing information contained in
employers' and insurer carriers' national databases. For pathology, laboratory,
and radiological services and durable medical equipment, the payment system
will set fees at 85% of 90% of the 75th percentile of actual charges. For
purposes of this section, "geozip" means an area defined by reference
to United States ZIP Codes; Delaware shall consist of 1 "197 geozip"
(comprised of all areas within the State where the address has a ZIP Code
beginning with the 3 digits "197" or "198"), and 1
"199 geozip" (comprised of all areas within the State where the
address has a ZIP Code beginning with the 3 digits of "199"). If a
geozip does not have the necessary number of charges and fees to calculate a
valid percentile for a specific procedure, treatment, or service, the Health Care
Advisory Panel in its discretion may combine data from Delaware's 2 geozips for
a specific procedure, treatment, or service. Those fees shall then be subject
to the adjustments described in paragraphs (3)d. and e. of this section in
subsequent years.
b.
On a 1-time basis in 2013, with respect to all possible procedures, treatments,
and services for which there was insufficiently reliable data prior to 2013 for
the Health Care Advisory Panel to determine a payment based upon the formula
described above, the Health Care Advisory Panel shall use a formula based upon
relative value units as determined by the Centers for Medicare and Medicaid
Services to determine fees for said procedures, treatments, and services. Those
fees shall then be subject to the adjustments described in paragraphs (3)d. and
e. of this section in subsequent years.
c.
For procedures, treatments, and services not covered by paragraph (3)a. or b.
of this section or other provisions of this chapter, the Health Care Advisory
Panel may recommend an alternative payment system.
d.
The payment system will be adjusted yearly based on percentage changes to the
Consumer Price Index-Urban, U.S. City Average, All Items, as published by the
United States Bureau of Labor Statistics. After January 17, 2010, the Health
Care Advisory Panel shall review the geozip reporting system and make a
recommendation concerning whether the State should operate its workers'
compensation health care payment system on a geozip basis or on a single
statewide basis.
e. Notwithstanding
the above, the payment system shall not be adjusted for inflation between July
1, 2013, and January 1, 2016. After January 1, 2016, the payment system shall
resume its adjustment as described above and in paragraph (14) of this section,
but inflation increases for the time period July 1, 2013, through January 1,
2016, shall not be recouped.
(4) Upon adoption of the health care payment system, an
employer and/or insurance carrier shall pay the lesser of the rate set forth by
the payment system or the health care provider's actual charge. If an employer
or insurance carrier contracts with a provider for the purpose of providing
services under this chapter, the rate negotiated in any such contract shall
prevail.
(5) Whenever the health care payment system does not set a
specific fee for a procedure, treatment or service in the schedule, the amount
of reimbursement shall be at 85% of actual charge.
(6) Procedures and requirements for promulgation of health care
payment system. — The health care payment system shall include provisions for
health care treatment and procedures performed outside of the State of
Delaware. If any procedure, treatment or service is rendered by a health care
provider, hospital or ambulatory surgery center, who is licensed or permitted
to render such procedure, treatment or service within the State of Delaware,
but performs such procedure, treatment or service outside of the State of
Delaware, the amount of reimbursement shall be the amount as set forth in the
health care payment system. In the event that a procedure, treatment or service
is rendered outside the State of Delaware by a health care provider, hospital
or ambulatory surgery center, not licensed or permitted to render such
procedure, treatment or service within the State of Delaware, the amount of reimbursement
shall be the greater of:
a.
The amount set forth in the workers' compensation health care payment system or
a fee schedule adopted by the state in which the procedure, treatment or
service is rendered, if such a schedule has been adopted; or
b.
The amount that would be authorized by the payment system adopted pursuant to
this chapter if the service or treatment were performed in the geozip where the
injury occurred or where the employee was principally assigned.
Charges
for a procedure, treatment or service outside the State of Delaware shall be
subject to the instructions, treatment guidelines, and payment guides and
policies in the health care payment system.
(7) The health care payment system shall include separate
service categories for the fields of: ambulatory surgical treatment centers,
anesthesia and related services, dental and related services, hospital care,
and professional services. The Health Care Advisory Panel is directed to
implement a specific cap on fees for anesthesia, which shall not be dependent
on current charges, by January 1, 2014.
(8) Hospital reimbursement developed in the healthcare payment
system shall be determined in accordance with the following provisions:
a.
Hospital fees billed for inpatient services, outpatient surgical services, and
emergency services provided to injured workers pursuant to this chapter shall
be reimbursed at a rate equal to 80.0% of each hospital's current actual
charges as of date of service, subject to adjustment provided by this paragraph.
Hospital fees billed for outpatient nonsurgical services shall be billed
subject to the provisions of paragraphs (3), (4) and (6) of this section;
whenever the healthcare payment system does not set a specific fee for a
procedure, treatment or service in the schedule, the amount of reimbursement
shall be at 80.0% of each hospital's current actual charges as of date of
service, subject to adjustment provided by this paragraph. On October 31, 2012,
and every year thereafter by the same date, each hospital, with the exception
of pediatric hospitals, shall provide to the Delaware Healthcare Association
(DHA) a written report submitted by each hospital's independent financial
auditor or certified public accountant setting forth its blended rate increase
or decrease for the prior year. Within 30 days of receipt of the aforementioned
reports, the DHA shall submit to the Department of Labor a written report
prepared by an independent financial auditor or certified public accountant
setting forth the following:
1. The arithmetic average of the blended rate increases or
decreases for the hospitals submitting reports to the DHA pursuant to this
subsection; and
2. A statement as to whether the hospitals have changed their
mark-up methodologies for implants, supplies and devices.
The
aforementioned report submitted by the DHA to the Department of Labor shall
include copies of the individual hospitals reports to the DHA, as referenced
above, but shall not identify the individual hospitals by name. Inpatient and
outpatient pharmaceutical charges shall be excluded from the blended rate
calculation referenced above. Implants, supplies and other cost-based services
shall also be excluded from the blended rate calculation referenced above as
long as the mark-up factor does not change from 1 year to the next. However, if
the mark-up factor changes, the percentage increase or decrease, confirmed by
each hospital through its annual financial statement, as referenced herein,
shall be included in the blended rate calculation for that year. The Department
of Labor shall, through a request for proposal (RFP) process, retain an
independent financial auditor(s) or certified public accountant(s) to verify
the validity of the rate change as it is set forth in the report submitted by
the DHA. The DHA shall cooperate fully with any request for information made by
the Department of Labor's retained financial advisor. Any proprietary
information obtained, received or reviewed by the Department of Labor and/or
their financial advisor(s) shall remain privileged and confidential, not
subject to disclosure pursuant to the provisions of Chapter 100 of Title 29.
Based upon the information received, the Department of Labor's financial
advisor shall calculate the overall rate change applicable to all hospitals for
the following year. If the arithmetic average of the blended rate for the
hospitals submitting reports to the DHA pursuant to this subsection is greater
than the Consumer Price Index-Urban, U.S. City Average, as published by the
United States Bureau of Labor Statistics (CPI-U), each hospital's reimbursement
rate shall be reduced by the difference between such blended rate and the
CPI-U. If the arithmetic average of the blended rate for the hospitals
submitting reports to the DHA pursuant to this paragraph is less than the
CPI-U, each hospital's reimbursement rate shall be increased by the difference
between such blended rate and the CPI-U. Such calculation shall be completed no
later than January 31 of each year. The overall rate change shall be instituted
on January 31, 2013, and every year thereafter on the same date. Reasonable
costs associated with the overall rate change verification and calculation, as
referenced above, shall be reimbursed to the Department of Labor by the DHA.
Such verification may be subject to further review and/or audit by the
Department of Insurance. Reasonable costs of any review or audit for purposes
of this section shall be reimbursed to the Department of Insurance by the DHA.
The failure on the part of any hospital and/or the DHA to comply with the
requirements set forth above shall result in the nonpayment of charges during
the period of noncompliance. Notwithstanding any language to the contrary, no
increase in a hospital's reimbursement rate shall be permitted between July 1,
2013, and January 1, 2016. No reimbursement rate increases on or after January
1, 2016, shall allow for recoupment of increases that might otherwise have been
permitted by this paragraph between July 1, 2013, and January 31, 2016.
b.
Healthcare provider services provided in an emergency department of a hospital,
or any other facility subject to the Federal Emergency Medical Treatment and
Active Labor Act, 42 U.S.C. §1395dd, and any emergency medical services
provided in a prehospital setting by ambulance attendants and/or paramedics,
shall be exempt from the healthcare payment system and shall not be subject to
the requirement that a healthcare provider be certified pursuant to §2322D of
this title, requirements for preauthorization of services, or the healthcare
practice guidelines adopted pursuant to §2322C of this title.
c.
The hospital reimbursement rate will be adjusted yearly as set forth in
paragraph (8)a. of this section, except as otherwise indicated. Notwithstanding
this yearly overall rate adjustment, the Health Care Advisory Panel, beginning
February 1, 2015, and every 3 years thereafter, shall review the overall rate
changes and make a determination whether the overall rate change reimbursement
method adequately addresses the intent of the General Assembly as set forth in
paragraph (1) of this section. The Health Care Advisory Panel shall provide the
Secretary of Labor with its determination and any proposal to address concerns
that may be identified during its review.
(9) Ambulatory Surgery Center ("ASC") reimbursement
developed in the healthcare payment system shall be determined in accordance
with the following provisions:
a.
Ambulatory Surgery Center fees billed for services provided to injured workers
pursuant to this chapter by an ASC shall be reimbursed at a rate equal to 85%
of each ASC's current actual charges for such services as of date of service,
subject to adjustment provided by this subsection as follows: On October 31,
2012, and every year thereafter by the same date, each ASC shall provide to the
Department of Labor its rate change for the prior fiscal year. Verification of
such rate change shall be provided by each ASC to the Office of Workers'
Compensation in accordance with the above through a written report submitted by
each ASC's independent financial auditor or certified public accountant. The
Department of Labor shall, through a request for proposal (RFP) process, retain
an independent financial auditor or auditors or certified public accountant or
accountants to verify the validity of the rate change submitted by each ASC.
Each ASC shall cooperate fully with any request for information made by the
Department of Labor's retained financial advisor. Any proprietary information
obtained, received or reviewed by the Department of Labor and/or their
financial advisor(s) shall remain privileged and confidential, and not subject
to disclosure pursuant to the provisions of Chapter 100 of Title 29. Based upon
the information received, the Department of Labor's financial advisor shall
calculate the rate change applicable to each ASC for the following year. If any
ASC's rate change is greater than the CPI-U, Medical, then that ASC's
reimbursement rate shall be reduced by the difference between that ASC's rate
change and the CPI-U, Medical. If any ASC's rate change is less than the CPI-U,
Medical, then that ASC's reimbursement rate shall be increased by the
difference between that ASC's rate change and the CPI-U, Medical. Such
calculation shall be completed no later than January 31 of each year. The rate
changes for the ASCs, as referenced above, shall be instituted on January 31,
2013, and every year thereafter on the same date. Reasonable costs associated
with each rate change verification and calculation, as referenced above, shall
be reimbursed to the Department of Labor by the ASC for which the rate changes
verification and calculation has been performed. Such verification may be
subject to further review and/or audit by the Department of Insurance.
Reasonable costs of any review or audit for purposes of this section shall be
reimbursed to the Department of Insurance by the ASC and/or ASCs whose billing
is audited. The failure on the part of any ASC to comply with the requirements
set forth above shall result in the nonpayment of charges during the period of
noncompliance.
b.
Ambulatory Surgery Center reimbursement rates will be adjusted yearly as set
forth in paragraph (9)a. of this section. Notwithstanding this yearly overall
rate adjustment, the Health Care Advisory Panel, beginning February 1, 2015,
and every 3 years thereafter, shall review the overall rate changes and make a
determination whether the overall rate change reimbursement method adequately
addresses the intent of the General Assembly as set forth in paragraph (1) of
this section. The Health Care Advisory Panel shall provide the Secretary of
Labor with its determination and any proposal to address concerns that may be
identified during its review.
c.
The Health Care Advisory Panel is directed to develop by January 1, 2014 a
system of maximum allowable payments for services provided in Ambulatory
Surgical Centers which shall result in stable charges and be cost neutral with
respect to medical costs. Upon the implementation of this system of maximum
allowable payments for treatments in Ambulatory Surgical Centers, paragraphs
(9)a. and b. of this section shall cease to have legal effect.
d.
Notwithstanding any language to the contrary, no adjustments for inflation
shall be made to any payment schedule developed pursuant to this subsection
until at least January 1, 2016. Subsequent to January 1, 2016, no permitted
inflation increases shall allow for recoupment of inflation-based expenses
incurred prior to January 31, 2016.
(10) Professional service fees developed in the health care
payment system shall be determined in accordance with the following provisions:
a.
The payment system for professional services shall conform to the Current
Procedural Terminology ("CPT"), American Medical Association, 515
North State Street, Chicago, Illinois, 60610.
b.
Services covered by the payment system shall include evaluation and management,
surgery, physician, medicine, radiology, pathology and laboratory,
chiropractic, physical therapy, and other services covered under the CPT.
c.
The health care payment system shall require that services be reported with the
Healthcare Common Procedural Coding System Level II ("HCPCS Level
II") or CPT codes that most comprehensively describe the services
performed. Proprietary bundling edits more restrictive than the National
Correct Coding Policy Manual in Comprehensive Code Sequence for Part B Medicare
Carriers, Version 12.0, U.S. Department of Health and Human Services, Centers
for Medicare and Medicare Services, 7500 Security Boulevard, Baltimore,
Maryland, 21244, shall be prohibited. Bundling edits is the process of
reporting codes so that they most comprehensively describe the services
performed.
d.
An allied health care professional, such as a certified registered nurse
anesthetist ("CRNA"), physician assistant ("PA"), or nurse
practitioner ("NP"), shall be reimbursed at the same rate as other
health care professionals when the allied health care professional is
performing, coding and billing for the same services as other health care
professionals if a physician health care provider is physically present when
the service or treatment is rendered, and shall be reimbursed at 80% of the
primary health care provider's rate if a physician health care provider is not
physically present when the service or treatment is rendered.
e.
Charges of an independently operated diagnostic testing facility shall be
subject to the professional services and HCPCS Level II health care payment
system where applicable. An independent diagnostic testing facility is an
entity independent of a hospital or physician's office, whether a fixed
location, a mobile entity, or an individual nonphysician practitioner, in which
diagnostic tests are performed by licensed or certified nonphysician personnel
under appropriate physician supervision.
f.
The Health Care Advisory Panel shall adopt and recommend regulations pertaining
to the methodology for updating the fee schedule for professional service fees
developed in the health care payment system as set forth in paragraphs (5),
(10)a., and (10)c. of this section.
(11) As part of the health care payment system, the Health Care
Advisory Panel shall adopt and recommend a reimbursement schedule for
pathology, laboratory and radiological services and durable medical equipment.
The Health Care Advisory Panel shall implement by September 1, 2013, a specific
limitation on drug screenings absent pre-authorization and a specific
limitation on per-procedure reimbursements for drug testing.
(12) As part of the health care payment system, the Health Care
Advisory Panel shall adopt and recommend a formulary and fee methodology for
pharmacy services, prescription drugs and other pharmaceuticals. The formulary
and fee methodology system developed by the Health Care Advisory Panel for
pharmacy services, prescription drugs and other pharmaceuticals shall include
by September 1, 2013, a mandated discount from average wholesale price that
shall be defined by the State, a ban on repackaging fees, and adoption of a
preferred drug list.
(13) Fees for nonclinical services, such as retrieving, copying
and transmitting medical reports and records, testimony by affidavit,
deposition or live testimony at any hearing or proceeding, or completion and
transmission of any required report, form or documentation, and associated
regulations and procedures for the determination of and verification of containment
of fees, shall be developed and proposed by the Health Care Advisory Panel, and
adopted as part of the health care payment system. Such fees shall be revised
periodically on the recommendation of the Health Care Advisory Panel to reflect
changes in the cost of providing such services. Following the adoption of the
initial health care payment system, adjustments to fees for nonclinical
services shall be adopted by regulation of the Department of Labor pursuant to
Chapter 101 of Title 29. The nonclinical service fees adopted pursuant to this
paragraph shall apply to all services provided after the effective date of the
regulation, regardless of the date of injury.
(14) Subject to the foregoing provisions, the health care
payment system authorized by this section shall be approved and proposed by the
Health Care Advisory Panel. Thereafter, the health care payment system shall be
adopted by regulation of the Department of Labor pursuant to Chapter 101 of
Title 29. Such regulation shall be promulgated and adopted within 180 days of
the first meeting of the Health Care Advisory Panel. One year after the
effective date of the regulation and each January thereafter, the Department of
Labor shall make an automatic adjustment to the maximum payment for a procedure,
treatment or service in effect in January of that year. Except with respect to
hospital charges that shall be adjusted in accordance with paragraph (8) of
this section, the Department of Labor shall increase or decrease the maximum
payment by the percentage change of increase or decrease in the Consumer
Product Index — Urban, U.S. City Average, All Items, as published by the United
States Bureau of Labor Statistics. The adjustment provided for in this section
shall not be applied to fees for nonclinical services and supplies.
Notwithstanding the above, the payment system shall not be adjusted for
inflation between July 1, 2013, and January 1, 2016. After January 1, 2016, the
payment system shall resume its adjustment as described above, but inflation
increases for the time period July 1, 2013, through January 1, 2016, shall not
be recouped.
76 Del. Laws, c. 1, §11; 76 Del. Laws, c. 143, §§1, 2; 77 Del. Laws, c. 94, §§1-4; 78 Del. Laws, c. 186, §1; 78 Del. Laws, c. 391, §1; 79 Del. Laws, c. 55, §2.;
§2322B Procedures and requirements for promulgation of health care payment system.
The health care payment system developed pursuant to this section shall be subject to the following procedures and requirements:
(1) The intent of the General Assembly in authorizing a health care payment system is to reduce overall medical expenditures for the treatment of workers' compensation related injuries by 33% by January 31, 2017, and to reduce said expenditures by 20% by January 31, 2015.
(2) The health care payment system shall include payment rates, instructions, guidelines, and payment guides and policies regarding application of the payment system. When completed, the payment system shall be published on the Internet at no charge to the user via a link from the Office of Workers' Compensation website at http://dia.delawareworks.com/workers-comp/, or a successor website. The payment system shall also be made available in written form at the Office of Workers' Compensation during regular business hours.
(3)The maximum allowable payment for health care related payments covered under this chapter shall be the lesser of the health care provider's actual charges or the fee set by the payment system.
(a)The Workers' Compensation Oversight Panel shall, by October 1, 2014, establish a fee schedule for all Delaware workers' compensation funded procedures, treatments, and services based on the Resource Based Relative Value Scale ("RBRVS"), Medical Severity Diagnosis Related Group(MS-DRG), Ambulatory Payment Classification (APC), or equivalent scale used by the Centers for Medicare and Medicaid Services.The RBRVS, MS-DRG, APC, or other equivalent factor shall be multiplied by a Delaware specific geographically adjusted factor to ensure adequate participation by providers.The fee schedule shall result in a reduction of 20% in aggregate workers compensation medical expenses by the year beginning January 31, 2015, an additional reduction of 5% of 2014 expenses by the year beginning January 31, 2016, and an additional reduction of 8% of 2014 expenses by the year beginning January 31, 2017.The aggregate workers compensation medical expenses required by this subparagraph shall be attained through reimbursement reductions of equal percentages among hospitals, ambulatory surgical centers, and other health care providers; therefore, by January 31, 2015, the fee schedule shall reflect a reduction of 20% in workers compensation medical expenses paid to hospitals, a reduction of 20% in workers compensation medical expenses paid to ambulatory surgical centers, and a reduction of 20% in workers compensation medical expenses paid to other health care providers.This formula shall also be used for the 5% reduction required by January 31, 2016 and the 8% reduction required by January 31, 2017.
(b)In addition, by January 31, 2017, no individual procedure in Delaware paid for through the workers' compensation system (as identified by HCPCS level 1 or level 2 code) shall be reimbursed at a rate greater than 200% of that reimbursed by the federal Medicare system, provided that radiology services may be reimbursed at up to 250% of the federal Medicare reimbursement and surgery services may be reimbursed at up to 300% of the federal Medicare reimbursement.
(c)The Workers' Compensation Oversight Panel shall report to the Governor and General Assembly by January 31, 2016 with respect to medical savings recognized as a result of this paragraph (3) and possible unforeseen consequences of the procedure-specific caps required by subparagraphs (3)(b) and (5), and the General Assembly may at that time reconsider the specific percentage caps required by subparagraphs (3)(b) and (5).The cost reductions required by subparagraph (3)(a) shall be permanent, with the exception of inflation increases beginning in 2018 as permitted by paragraph 5 of this section.
(4)An independent actuary appointed by the Secretary of Labor shall verify for the Secretary that the fee schedule developed by the Workers Compensation Oversight Panel under paragraph (3) of this section complies with its requirements.If the fee schedule does not comply with its requirements, or is not completed by October 1, 2014, the Secretary of Labor shall promulgate a fee schedule meeting the requirements of paragraph (3) by regulation.
(5)Beginning on January 1, 2018, the payment system will be adjusted yearly based on percentage changes to the Consumer Price Index-Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics.Notwithstanding the annual CPI-Urban increase permitted by this paragraph, no individual procedure in Delaware paid for through the workers' compensation system (as identified by HCPCS level 1 or level 2 code) shall be reimbursed at a rate greater than 200% of that reimbursed by the federal Medicare system, provided that radiology services may be reimbursed at up to 250% of the federal Medicare reimbursement and surgery services may be reimbursed at up to 300% of the federal Medicare reimbursement.The Workers Compensation Oversight Panel may, without consent of the General Assembly and Governor, reduce reimbursements for any procedures it deems appropriate, but cannot increase reimbursements beyond the amounts permitted by this Chapter.
(6) Upon adoption of the health care payment system, an employer and/or insurance carrier shall pay the lesser of the rate set forth by the payment system or the health care provider's actual charge. If an employer or insurance carrier contracts with a provider for the purpose of providing services under this chapter, the rate negotiated in any such contract shall prevail.
(7) The health care payment system shall include provisions for health care treatment and procedures performed outside of the State of Delaware. If any procedure, treatment or service is rendered by a health care provider, hospital or ambulatory surgery center, who is licensed or permitted to render such procedure, treatment or service within the State of Delaware, but performs such procedure, treatment or service outside of the State of Delaware, the amount of reimbursement shall be the amount as set forth in the health care payment system. In the event that a procedure, treatment or service is rendered outside the State of Delaware by a health care provider, hospital or ambulatory surgery center, not licensed or permitted to render such procedure, treatment or service within the State of Delaware, the amount of reimbursement shall be the greater of:
a. The amount set forth in the workers' compensation health care payment system or a fee schedule adopted by the state in which the procedure, treatment or service is rendered, if such a schedule has been adopted; or
b. The amount that would be authorized by the payment system adopted pursuant to this chapter if the service or treatment were performed in the geozip where the injury occurred or where the employee was principally assigned.
Charges for a procedure, treatment or service outside the State of Delaware shall be subject to the instructions, treatment guidelines, and payment guides and policies in the health care payment system.
(8) Fees for nonclinical services, such as retrieving, copying and transmitting medical reports and records, testimony by affidavit, deposition or live testimony at any hearing or proceeding, or completion and transmission of any required report, form or documentation, and associated regulations and procedures for the determination of and verification of containment of fees, shall be developed and proposed by the Workers' Compensation Oversight Panel, and adopted as part of the health care payment system. Such fees shall be revised periodically on the recommendation of the Panel to reflect changes in the cost of providing such services. Following the adoption of the initial health care payment system, adjustments to fees for nonclinical services shall be adopted by regulation of the Department of Labor pursuant to Chapter 101 of Title 29. The nonclinical service fees adopted pursuant to this paragraph shall apply to all services provided after the effective date of the regulation, regardless of the date of injury.
(9) As part of the health care payment system, the Workers' Compensation Oversight Panel shall adopt, recommend, and maintain a formulary and fee methodology for pharmacy services, prescription drugs and other pharmaceuticals. The formulary and fee methodology system developed by the Workers' Compensation Oversight Panel for pharmacy services, prescription drugs and other pharmaceuticals shall include a mandated discount from average wholesale price that shall be defined by the State, a ban on repackaging fees, and adoption of a preferred drug list.
§2322C Development of health care practice guidelines.
Health care practice guidelines shall be developed in accordance with the following provisions:
(1) The Health Care Advisory Panel Workers'
Compensation Oversight Panel shall adopt, and recommend and
maintain a coordinated set of health care practice guidelines and
associated procedures to guide utilization of health care treatments in
workers' compensation, including but not limited to care provided for the
treatment of employees by or under the supervision of a licensed health care
provider, prescription drug utilization, inpatient hospitalization and length
of stay, diagnostic testing, physical therapy, chiropractic care and palliative
care. The health care practice guidelines shall apply to all treatments provided
after the effective date of the regulation referred to in paragraph (7) of this
section, regardless of the date of injury.
(2) The guidelines shall be, to the extent permitted by the most current medical science or other applicable science, based on well-documented scientific research concerning efficacious treatment for injuries and occupational disease. To the extent that well-documented scientific research concerning efficacious treatment is not available at the time of adoption or revision of the guidelines, the guidelines shall be based upon the best available information concerning national consensus regarding best health care practices in the relevant health care community.
(3) The guidelines shall, to the extent practical consistent with this section, address treatment of those physical conditions which occur with the greatest frequency (for services compensable under this chapter), or which require the most expensive treatments (for services compensable under this chapter), based upon currently available Delaware data.
(4) The guidelines shall contain a section guiding the utilization of prescription medications.
(5) The original health care practice guidelines may be
based upon an existing model, already in use, to guide treatment of medical
care for workers' compensation. Additional guidelines may be initially adopted,
pursuant to the same criteria, to obtain coverage of areas or issues of
treatment not included in other adopted guidelines. In no event shall multiple
guidelines covering the same aspects of the same medical condition be
simultaneously in force.
(6) Services rendered by any health care provider certified to
provide treatment services for employees shall be presumed, in the absence of
contrary evidence, to be reasonable and necessary if such services conform to
the most current version of the Delaware health care practice guidelines.
Services provided by health care providers that are not certified shall not be
presumed reasonable and necessary unless such services are preauthorized by the
employer or insurance carrier, subject to the exception set forth in §2322D(b)
of this title. It is intended that these guidelines will be produced recommended
to the Panel by Health Care Advisory Panel Panel subcommittees in
coordination with a qualified contractor with expertise in establishing
treatment guidelines, developing the rules that define the use of such
guidelines, and disseminating the guidelines in a manner that streamlines the
delivery of health care.
(7) Subject to the foregoing provisions, after receiving the
approval and recommendation of the Health Care Advisory Panel, the guidelines
shall be adopted by regulation of the Department of Labor pursuant to Chapter
101 of Title 29. Such regulations shall be adopted and effective not later than
1 year after the first meeting of the Health Care Advisory Panel. Health
care practice guidelines shall be subject to review and revision by the Health
Care Advisory Panel Workers' Compensation Oversight Panel on at
least an annual basis. It is the intent of the General Assembly that the
development of health care guidelines will be directed recommended by
a predominantly medical or other health professional panel subcommittee,
recognizing that health care professionals are best equipped to determine
appropriate treatment. It is further intended that subcommittees comprised of
representatives from appropriate specialties will make comment and offer
recommendations to the Health Care Advisory Panel Workers'
Compensation Oversight Panel.
§2322D Certification of health care providers.
(a)(1) Certification shall be required for a health care provider to provide treatment to an employee, pursuant to this chapter, without the requirement that the health care provider first preauthorize each health care procedure, office visit or health care service to be provided to the employee with the employer or insurance carrier. The provisions of this subsection shall apply to all treatments to employees provided after the effective date of the rule provided by subsection (c) of this section, regardless of the date of injury. A health care provider shall be certified only upon meeting the following minimum certification requirements:
a. Have a current license to practice, as applicable;
b. Meet other general certification requirements for the specific provider type;
c. Possess a current and valid Drug Enforcement Agency ("DEA") registration, unless not required by the provider's discipline and scope of practice;
d. Have no previous involuntary termination from participation in Medicare, Medicaid or the Delaware workers' compensation system, which shall be determined to be inconsistent with certification under regulations adopted pursuant to subsection (c) of this section;
e. Have no felony convictions in any jurisdiction, under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation, which shall be determined to be inconsistent with certification under regulations adopted pursuant to subsection (c) of this section; and
f. Provide proof of adequate, current professional malpractice and liability insurance.
(2) The certification rules shall require that any health care provider to be certified agree to the following terms and conditions:
a. Compliance with Delaware workers' compensation laws and rules;
b. Maintenance of acceptable malpractice coverage;
c. Completion of State-approved continuing education courses in workers' compensation care every 2 years;
d. Practice in a best-practices environment, complying with practice guidelines and Utilization Review Accreditation Council ("URAC") utilization review determinations;
e. Agreement to bill only for services and items performed or provided, and medically necessary, cost-effective and related to the claim or allowed condition;
f. Agreement to inform an employee of that employee's liability for payment of noncovered services prior to delivery;
g. Acceptance of reimbursement and not unbundled charges into separate procedure codes when a single procedure code is more appropriate; and
h. Agreement not to balance bill any employee or employer. Employees shall not be required to contribute a copayment or meet any deductibles.
(b) Notwithstanding the provisions of this section, any health care provider may provide services during 1 office visit, or other single instance of treatment, without first having obtained prior authorization, and receive reimbursement for reasonable and necessary services directly related to the employee's injury or condition at the health care provider's usual and customary fee, or the maximum allowable fee pursuant to the workers' compensation health care payment system adopted pursuant to § 2322B of this title, whichever is less. The provisions of this subsection are limited to the occasion of the employee's first contact with any health care provider for treatment of the injury, and further limited to instances when the health care provider believes in good faith, after inquiry, that the injury or occupational disease was suffered in the course of the employee's employment. The provisions of this subsection shall apply to all treatments to injured employees provided after the effective date of the rule provided by subsection (c) of this section, regardless of the date of injury.
(c) Subject to the foregoing provisions, complete
rules and regulations relating to provider certification shall be approved and
proposed by the Health Care Advisory Panel Workers Compensation
Oversight Panel. Thereafter, such regulations Regulations arising
from the Panel's work shall be adopted by regulation of the Department of
Labor pursuant to Chapter 101 of Title 29. Such regulations shall be adopted
and effective not later than 1 year after the first meeting of the Health Care
Advisory Panel.
§2322E Development of consistent forms for health care providers.
(a) The Health Care Advisory Panel Workers'
Compensation Oversight Panel is authorized and directed to approve and
propose and maintain standard forms for the provision of health care
services pursuant to this chapter.Upon such
recommendation by the Workers' Compensation Oversight Panel, such forms
and provisions governing their use shall be adopted by regulation of the
Department of Labor, pursuant to Chapter 101 of Title 29. Such regulations
shall be adopted and effective not later than 180 days after the first meeting
of the Health Care Advisory Panel. Forms authorized by this section shall
provide for prompt initial report of an employee's condition upon the initial
occurrence of injury treated pursuant to this chapter and upon reasonable
intervals thereafter to report the conditions and limitations of an employee.
At a minimum the initial reporting form shall provide for an outline of the
physical capabilities of the employee in order to enable and encourage the
injured employee to return to work at the highest level of capability.
(b) The health care provider most responsible for the treatment of the employee's work-related injury shall complete and submit, as expeditiously as possible and not later than 10 days after the date of first evaluation or treatment, a report of employee condition and limitations, on a form adopted for that purpose pursuant to this section, and shall expeditiously provide copies of the report of employee condition and limitations to the employee, the employer and the employer's insurance carrier, if applicable. In the event that an employee is treated and released from the emergency department of a hospital, the health care provider most responsible for follow up care, if applicable, or the emergency room attending physician, shall provide the report of employee condition and limitations to the employee upon release, and the employee shall be responsible for provision of the report to the employer and the employer's insurance carrier, if applicable, within the time period provided by the rules adopted pursuant to this section.
(c) Every health care provider shall prepare supplemental reports of employee condition and limitations on forms prescribed pursuant to this section, and shall expeditiously provide copies of the report of employee condition and limitations to the employee, the employer and the employer's insurance carrier, if applicable.
(d) Within 14 days of the issuance of an Agreement As To Compensation to an employee for any period of total disability, the employer shall provide to the health care provider/physician most responsible for the treatment of the employee's work-related injury and to the employer's insurance carrier, if applicable, a report of the modified-duty jobs which may be available to the employee. The insurance carrier for an insured employer shall send to such employer the aforementioned report for completion, and shall be independently responsible for providing a completed report of modified-duty jobs to the health care provider/physician. The health care provider portion of the employer's modified duty availability report must be signed and returned by the health care provider within 14 days of the next date of service after receipt of the form from the employer, but not later than 21 days from the health care provider's receipt of such form.
(e) Fees for completion, copying and transmission of the forms
shall be developed maintained by the Health Care Advisory
Panel Workers' Compensation Oversight Panel. The employer or the
employer's insurance carrier shall be liable for payment of the fee for all
such reports of employee condition and limitations, provided however, that the
employer or insurance carrier shall not be liable for any such reports,
requested by an employee more frequently than once during each 3-month period.
§2322F Billing and payment for health care services.
(j) Utilization review. — The Health
Care Advisory Panel Workers Compensation Oversight Panel shall develop
approve, propose and maintain a utilization review program. The intent
is to provide reference for employers, insurance carriers, and health care
providers for evaluation of health care and charges. The intended purpose of
utilization review services shall be the prompt resolution of issues related to
treatment and/or compliance with the health care payment system or practice
guidelines for those claims which have been acknowledged to be compensable. An
employer or insurance carrier may engage in utilization review to evaluate the
quality, reasonableness and/or necessity of proposed or provided health care
services for acknowledged compensable claims. Any person conducting a utilization
review program for workers' compensation shall be required to contract with the
Office of Workers' Compensation once every 2 years and certify compliance with
Workers' Compensation Utilization Management Standards or Health Utilization
Management Standards of Utilization Review Accreditation Council
("URAC") sufficient to achieve URAC accreditation or submit evidence
of accreditation by URAC. If a party disagrees with the findings following
utilization review, a petition may be filed with the Industrial Accident Board
for de novo review. Complete rules and regulations relating to utilization
review shall be approved and recommended approved, proposed and
maintained by the Health Care Advisory Panel Workers'
Compensation Oversight Panel. Thereafter, such rules Rules
recommended by the Panel shall be adopted by regulation of the Department
of Labor pursuant to Chapter 101 of Title 29. Such regulations shall be
adopted and effective not later than 1 year after the first meeting of the
Health Care Advisory Panel.
Section 3.The advisory organization designated by the Department of Insurance pursuant to Title 18, Section 2607 of the Delaware Code shall, within 90 days of enactment of this Act, file for approval by the Commissioner prospective loss costs that shall explicitly and individually account for the impact of any statutory changes in this Act.Any order issued by the Department of Insurance relating to said filing shall explicitly account for all statutory changes that are enumerated by the advisory organization in the filing required by this Section.