Workers’ Comp Regulations: The Trends, Updates and Predictions We Need to Know for 2020
The nation’s legislative landscape is complex. For workers’ compensation program administrators, keeping up with constantly changing procedures and policies has the added hurdle of complying with each state’s regulations.
At NWCDC, Brian Allen, vice president of government affairs for Mitchell’s Pharmacy Solutions, and Michele Hibbert-Iacobacci, senior vice president of regulatory compliance management for Mitchell’s Casualty Solutions Group, talked in-depth about some of the most pressing regulatory compliance trends facing workers’ compensation today. They also looked into what’s to come for the industry in 2020.
For those who were unable to attend “Regulatory Compliance Trends for 2019 and Beyond,” here’s what Allen and Hibbert-Iacobacci had to say.
Medical Billing Fraud Trends
- While not truly a fraudulent act, billing errors still have a fraud focus. The medical bill coding error rate, as reported by CMS for the 2017-18 year, was 8.1%.
- In that same time period, CMS reported a $31.6 billion loss due to medical billing errors. In six years, CMS reported $230 billion in losses due to medical billing errors.
- There are preventable billing mistakes that have a fraud element to them, including: unbundling, ‘frustrated’ coding, made-up coding, insufficient documentation and invalid diagnoses.
- ‘Frustrated’ coding refers to codes that are unlisted. This type of billing error, including made-up codes and miscoding, accounts for 10% of billed procedures.
- Another area of fraud in medical billing is potential fraud. Up-coding, billing out of order and mismatching of ER services are a few examples.
- Presumption laws have become highly prevalent in 2019 legislatures for first responders (including PTSD, mental health and cancer).
- These types of presumptions are starting to expand into other industries and professions. For example, mechanics who work on fire engines are looking for these types of presumptions; school teachers are starting to seek presumptions on PTSD; and jail guards and dispatchers are seeking presumptions as well.
- According to Allen and Hibbert-Iacobacci, as these other professions seek presumption laws, it will “create some potential legal issues down the road.”
- Drug formularies continue to post excellent utilization of opioids and all drugs, along with improved costs.
- Some states are already attempting to update their formularies, including New York, Montana, Illinois, Indiana, Kentucky and Nebraska. Of these, N.Y., Mont. and Ken. already have drug formularies in effect, while the rest are still working to both create and refine their formularies.
- States are continuing to expand legal access to marijuana. Because of this, on-going clinical trials are being conducted to identify and qualify medical uses of the drug and the potential side effects it may bring.
- More clarification on insurance reimbursement or payments are going to follow.
- “The big issue is that it’s still illegal at the federal level,” said Allen.
- In addition, more legislative decisions are being made on several factors surrounding the growth and use of the drug. Several states are reviewing home cultivation legality as well as open container laws.
- Other states are looking to allow medical marijuana use for all conditions and not just a few.
- Calif. has attempted a ballot in 2018 to legalize magic mushrooms but did not get enough signatures.
- Denver, Colorado has initialized a ballot initiative to decriminalize possession of magic mushrooms.
- Oregon is working on a ballot initiative for 2020.
- Iowa has attempted to legalize psilocybin, ibogaine and ecstasy.
- “Magic mushrooms” have been successfully used for smoking cessation and there is ongoing research on whether or not magic mushrooms can treat anxiety and depression.
- Prescribing rates of opioids have dropped, as reported by the CDC, WCRI and CWCI.
- The CDC reported that prescriptions per every 100 people had a drop from 81.3 in 2012 to 58.7 in 2017.
- According to WCRI, the total cost percentage of opioids has decreased from 22% to 13% from 2015 to 2018.
- And the CWCI found that the percentage of all prescriptions of opioids to injured workers has also dropped from 30.5% in 2009 to 18% in 2017.
- Currently, there are more than 90 bills in the state legislatures on opioid prescribing. On the federal level, Allen said that the John McCain opioid addiction and prevention act will be the one to watch as we move into 2020.
To close out the talk, Allen and Hibbert-Iacobacci discussed some of the trends to watch as we head into 2020. Directed managed care, drug fomularies and opioid prescribing limits topped the list.
They also said to keep an eye on the upcoming presidential election.
Political divide may continue to impact the way these legal trends are approached by local, state and national legislatures, said Allen. &