SB 537

Bill Subjects

Abstract

Existing law establishes a workers' compensation system, administered by the Administrative Director of the Division of Workers' Compensation, to compensate an employee for injuries sustained in the course of employment. Existing law requires the employer to provide medical, surgical, chiropractic, acupuncture, and hospital treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods. Existing law defines a "physician" for purposes of the workers' compensation laws to include physicians and surgeons, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners licensed by state law and within the scope of their practice. Existing law also requires the administrative director to post certain information on the division's internet website. This bill would require the administrative director to issue a report to the Legislature, on or before January 1, 2023, comparing potential payment alternatives for providers to the official medical fee schedule. The bill would also require, on or before January 1, 2024, and annually thereafter, the administrative director to publish on the division's internet website provider utilization data for physicians, as defined above, who treated 10 or more injured workers during the 12 months before July 1 of the previous year, including the number of injured workers treated by the physician and the number of utilization review decisions that resulted in a modification or denial of a request for authorization of medical treatment based upon a determination of medical necessity. The bill would authorize the administrative director to withhold data if deemed necessary to protect patient privacy. Existing law prohibits a person or public or private entity not a party to a claim for workers' compensation benefits from obtaining individually identifiable information obtained or maintained by the division regarding that claim, except as provided. Existing law requires the administrative director to develop a cost-efficient workers' compensation information system and authorizes the administrative director to use individually identifiable information for purposes of creating and maintaining that system. This bill would require the administrative director to use individually identifiable information for purposes of creating provider medical utilization data as described above. Existing law requires a workers' compensation insurer, third-party administrator, or other entity that requires, or pursuant to regulation requires, a treating physician to obtain either utilization review or prior authorization in order to diagnose or treat injuries or diseases compensable pursuant to specified law, to ensure the availability of those services from 9 a.m. to 5:30 p.m. Pacific standard time of each normal business day. Existing law defines a normal business day for these purposes to exclude Saturdays, under specified circumstances, Sundays, and certain holidays, as described. This bill would revise the definition of a normal business day for these purposes to specifically exclude every Saturday, Sunday, and specified other holidays. The bill would also make technical changes. Existing law authorizes an insurer, employer, or entity that provides physician network services to establish or modify a medical provider network for providing medical treatment to injured employees and imposes various duties upon the insurer, employer, or entity in connection with the network. Existing law requires every medical provider network to post on its internet website a roster of all treating physicians in the medical provider network and requires every network to provide to the administrative director the internet website address of the network and of its roster of treating physicians. Existing law requires the administrative director to adopt a medical treatment utilization schedule. Existing law authorizes the administrative director to investigate complaints and to conduct random reviews of approved medical provider networks. This bill would, commencing July 1, 2021, require every medical provider network to post on its internet website a roster of participating providers and to provide to the administrative director the internet website address of the network and of its roster of participating providers. The bill would revise the authority of the administrative director by giving the administrative director authority and discretion to investigate complaints, conduct random reviews, and take enforcement action against medical provider networks, an entity that provides ancillary services, as defined, or an entity providing services for or on behalf of the medical provider network or its providers, regarding noncompliance with, among others, the internet address and roster requirements imposed on those networks. Existing law requires a physician providing treatment to send a request for authorization for medical treatment to the claims administrator. Existing law requires a provider's itemized request for payment to be submitted to an employer within 12 months of the date of service or within 12 months of the date of discharge for inpatient facility services for services provided on or after January 1, 2017. This bill would prohibit an entity other than the requesting physician or provider from altering or amending a request for authorization for medical treatment prior to the submission of the request to the claims administrator, and would state that this provision is declaratory of existing law. The bill would require an itemized request for payment for services to be submitted to an employer with the physician's or provider's national provider identifier number. Existing law requires the administrative director to adopt a schedule for payment of home health care services that are not covered by a Medicare fee schedule and are not otherwise covered by the official medical fee schedule described above. Existing law authorizes a health care provider or licensed health facility and a contracting agent, employer, or carrier to contract for reimbursement rates different from those in the fee schedule. This bill, on and after July 1, 2021, would require an entity that provides physician or ancillary network service to provide a payor with a written disclosure of the reimbursement amount paid to the provider with a rate sheet if a contracted reimbursement rate is more than 20% below the official medical fee schedule, as specified. The bill would authorize an entity that provides physician or ancillary network services to require a payor to sign a nondisclosure agreement before providing that disclosure.