OVERVIEW OF WORKERS’ COMPENSATION FOR WEST VIRGINIA PROVIDERS March 2012 Leah Klinke West Virginia United Insurance Services Health Partners Network Overview of WV Workers’ Comp • History of Workers’ Comp in West Virginia • Jurisdiction – Which State’s rules will apply? • West Virginia Rules & Reimbursement • Other State Rules & Reimbursement • Important Documents & Reference Tools HISTORY OF WORKERS’ COMP IN WEST VIRGINIA History of Workers’ Comp in WV • Prior to January 1, 2006, workers’ compensation was • • • • • managed exclusively by the State of West Virginia Brickstreet was established by the State of West Virginia on January 1, 2006 as an alternative plan to the state insurance fund. As the sole private entity in the state, Brickstreet enjoyed a monopoly in the West Virginia market. On November 1, 2007, Brickstreet established a PPO product “StreetSelect” to prepare for coming competition. On July 1, 2008, the West Virginia Workers’ Compensation market opened to private insurers. Brickstreet became just one of many private insurers in the market. History of Workers’ Comp in WV • West Virginia’s workers’ compensation system transitioned from a simple single payer system to a competitive multi-payer system virtually overnight. Why Change? • Brickstreet was formed to replace a state-run system that was expensive for employers, but provided generous benefits for insured employees. • The market was then opened up to competition between many insurers. • The goal for the system was to introduce competition and lower premiums for employers in the state. Changes for Providers • In the single insurer system, providers knew who they were dealing with and what they would expect to be paid when an injured worker was treated in their facility. • Under the new system, providers have to do a lot more work to find out who they are dealing with and whether they are in-network for a particular employee/patient. • Reimbursement is challenging for many physicians and hospitals as there is no longer a single fee schedule to apply to all provider bills. JURISDICTION – WHICH STATE’S RULES WILL APPLY? Jurisdiction - Which State’s rules will apply? • Jurisdiction [joor-is-dik-shuhn] noun • the right, power, or authority to administer justice by hearing and determining controversies. • power; authority; control. • The state with jurisdiction is the state that will determine what rules will apply to a particular claim. West Virginia rules do not automatically apply just because a patient received medical care in West Virginia. • The following questions will help you to determine which rules will apply to a particular bill. Jurisdiction - Which State’s rules will apply? • Question #1: Where does the employee primarily work? • In most of West Virigina’s surrounding states, the state in which the employee primarily works is considered the patient’s home state. • If the employee primarily works in more than one state, that employer may be required to purchase workers’ compensation insurance in both states. If so, jurisdiction will be determined by question #2. Jurisdiction - Which State’s rules will apply? • Question #2: Where was the employee injured? • If an employer carries work comp in WV and another state the state in which the employee was in at time of injury has jurisdiction over the claim Jurisdiction - Which State’s rules will apply? • Where can you find the information to answer the Jurisdiction question? • The “123 Form” is the form that should be filled out by each injured employee at the time of the injury to initiate a claim. This form has the patient list the location of their employer as well as the location where the injury occurred. If this form is available, it is a good source of information. Jurisdiction - Which State’s rules will apply? • Example #1 • A patient is an employee of Consolidated Coal. The patient works in more than one location: One in PA and one in WV. The patient was working at a West Virginia mine when injured. • In this example, the “Home State” could be West Virginia or Pennsylvania. Because the employee was injured in West Virginia, West Virginia's workers’ compensation rules should apply to this patient. Jurisdiction - Which State’s rules will apply? • Example #2 • A patient is an employee of First Energy. The patient lives in PA, but primarily works in Maryland reading meters. The patient was injured in Maryland, then seen at a West Virginia hospital. • In this example, the “Home State” would be Maryland because that is the state where the employee primarily works. WEST VIRGINIA RULES & REIMBURSEMENT West Virginia Rules and Regulations • State maximum medical reimbursement is set at 135% of Medicare for in and outpatient hospital and physician medical care. • Specific documents outlining the fee schedule can be found at: http://www.wvinsurance.gov/WorkersCompensation/WCManagedHe althCarePlansFeesschedule/Schedule.aspx Managed Health Care Plans (MHCPs) • West Virginia allows an “approved Managed Health Care Plan” (MHCP) to negotiate for contract rates outside of the state fee schedule since WC insurance is now privatized • Approved Managed Health Care Plans (MHCPs) are exempt from the state maximum fee schedule • Negotiated rates can be above the rates outlined in the state fee schedule • Because MHCPs are exempt from the state maximum, reimbursement from a non-contracted MHCP should be expected at 100% of billed charges. Approved MHCPs • • • • • • • CompNET 4COMP Network CompKey, Forte, Inc CorVel West Virginia KHA Solutions Group Travelers & Constitution Coventry Workers' Comp Services • GENEX Se • Liberty Mutual Services • • • • MedInsights, Inc. Rising-Rockport Bunch & Associates, LLC Brickstreet Mutual Insurance Company/ StreetSelect • Procura Management, Inc. HMOs • The Health Plan of the Upper Ohio Valley, Inc. Non Contracted - MHCPs • Providers should attempt to negotiate single case agreements with non-contracted MHCPs at rates above what the contracted MHCPs pay. • When no agreement is made in advance, payers may attempt to pay a rate below the provider’s billed charges. In these cases, an appeal needs to be made to the payer for additional payment. • Requiring non-contracted payer to agree to a rate above the state fee schedule in advance of services being rendered opens up the opportunity for a contract negotiation to get the payer in-network for future patients. Not Part of an MHCP • If a patient is covered under a plan that is not part of an approved MHCP, the reimbursement is expected to be at the state maximum of 135% of Medicare • Reimbursement is NOT limited to billed charges in WV • The Workers’ Compensation code states that these payers can contract for rates other than the state maximum Not Part of an MHCP • Example: • A patient who is a Wal-Mart employee who has been injured on the job attempts to schedule elective surgery at your facility. • The employer group/carrier is identified as a group that is not part of an MHCP in advance of scheduling. Negotiations should be initiated. • Employers and/or carriers who are not part of MHCPs are finding it difficult to coordinate care for injured employees as many providers will not take workers’ compensation cases. This creates an incentive for the employer and/or carrier to establish an agreement with a provider to provide the care their employee needs. Is this claim part of an MHCP? • Good Question! Here are some tips to help you out: • Develop a list of common employers and their insurance carrier. • Link those carriers to the approved MHCP (if any) • Distribute this list to patient access representatives and schedulers in the common Work related injury departments (e.g. orthopedics, neurology, emergency department). This will assist in proper insurance selection up front. It will also let the schedulers know whether a special agreement needs to be negotiated with an out of network payer/MHCP. • Facilitate completion of the 1-2-3 form if the patient arrives in your ED. The form tells the employer name and the location where the injury occurred. A template of the 1-2-3 form can be found on the insurance commission website. • The patient will also receive an “insurance card” once the claim is established showing the MHCP the patient is a part of. Is this claim part of an MHCP? • West Virginia law requires an insurance company to provide injured employees with an “insurance card” showing which MHCP the patient is a part of. This comes attached to a letter and is mailed to the patient once the claim is established. OTHER STATE RULES & REIMBURSEMENT Other State Rules & Reimbursement • For the most part, each state sets its own rates for patients who travel outside the home state for treatment or specifies that the out-of-state provider’s own states rates will apply. • Many providers have seen an increase in out-of-state claims due to energy production in the state which brings employees to work in West Virginia on a temporary basis. Other State Rules & Reimbursement • Pennsylvania – • Inpatient hospital claims are paid at a DRG calculation using version 12 DRGs based on the Harrisburg, PA locality. • Outpatient hospital is paid based on Medicare HCPCS rates out of Harrisburg, PA as of January 1, 1995 or when a new code was first introduced • Physician reimbursement is based on Medicare Part B reimbursement based on the Harrisburg, PA locality • Reimbursement is limited to the billed amount for all schedules listed above. Other State Rules & Reimbursement • Ohio – • Inpatient hospital claims are paid at 61% of billed charges. • Outpatient hospital is paid at 61% of billed charges. • Physician reimbursement is based on Ohio rates. Other State Rules & Reimbursement • Maryland – • No out of state treatment fee schedule is specified. • Will access PPO discounts where they are entitled (have seen One Net, First Health). • Otherwise, will pay based on WV State Fee schedule IMPORTANT DOCUMENTS & REFERENCE TOOLS Important Reference Tools • West Virginia law requires an insurance company to provide injured employees with an “insurance card” showing which MHCP the patient is a part of. • 123 Form contains valuable information related to the jurisdiction question such as the employer’s address and location where injury occurred. Important Reference Tools • State of West Virginia Workers’ Comp Insurance Validation System - https://www.ewccv.com/cvs/ • State of West Virginia Workers’ Comp Website: http://www.wvinsurance.gov/WorkersCompensation/ Important Reference Tools • State of West Virginia Workers’ Comp Insurance Validation System - https://www.ewccv.com/cvs/ Enter employer’s name and service date Important Reference Tools • State of West Virginia Workers’ Comp Insurance Validation System - https://www.ewccv.com/cvs/ Returns the name of the insurance company for that employer Questions?