Bill Text: CA SB146 | 2013-2014 | Regular Session | Chaptered
Bill Title: Workers' compensation: medical treatment: billing.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2013-08-19 - Chaptered by Secretary of State. Chapter 129, Statutes of 2013. [SB146 Detail]
Download: California-2013-SB146-Chaptered.html
BILL NUMBER: SB 146 CHAPTERED
BILL TEXT
CHAPTER 129
FILED WITH SECRETARY OF STATE AUGUST 19, 2013
APPROVED BY GOVERNOR AUGUST 19, 2013
PASSED THE SENATE JULY 3, 2013
PASSED THE ASSEMBLY JULY 1, 2013
AMENDED IN ASSEMBLY JUNE 13, 2013
AMENDED IN SENATE MARCH 6, 2013
INTRODUCED BY Senator Lara
JANUARY 31, 2013
An act to amend Section 4603.2 of the Labor Code, relating to
workers' compensation, and declaring the urgency thereof, to take
effect immediately.
LEGISLATIVE COUNSEL'S DIGEST
SB 146, Lara. Workers' compensation: medical treatment: billing.
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 his or her employment. Existing law
requires an employer to provide all medical services reasonably
required to cure or relieve the injured worker from the effects of
the injury, and generally provides for the reimbursement of medical
providers for services rendered in connection with the treatment of a
worker's injury. Existing law requires a pharmacy to submit its
request for payment with an itemization of services provided and the
charge for each service, a copy of all reports showing the services
performed, the prescription or referral from the primary treating
physician if the services were performed by a person other than the
primary treating physician, and any evidence of authorization for the
services that may have been received.
This bill would prohibit a copy of the prescription from being
required with a request for payment of pharmacy services, unless the
provider of services has entered into a written agreement, as
provided, that requires a copy of a prescription for a pharmacy
service, and would give any entity until March 31, 2014, to resubmit
pharmacy bills for payment, originally submitted on or after January
1, 2013, where payment was denied because the bill did not include a
copy of the prescription from the treating physician. The bill would
also clarify that an employer, insurer, pharmacy benefits manager, or
3rd-party claims administrator would not be precluded from
requesting a copy of a prescription during a review of any records of
prescription drugs dispensed by a pharmacy.
This bill would declare that it is to take effect immediately as
an urgency statute.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 4603.2 of the Labor Code is amended to read:
4603.2. (a) (1) Upon selecting a physician pursuant to Section
4600, the employee or physician shall notify the employer of the name
and address, including the name of the medical group, if applicable,
of the physician. The physician shall submit a report to the
employer within five working days from the date of the initial
examination, as required by Section 6409, and shall submit periodic
reports at intervals that may be prescribed by rules and regulations
adopted by the administrative director.
(2) If the employer objects to the employee's selection of the
physician on the grounds that the physician is not within the medical
provider network used by the employer, and there is a final
determination that the employee was entitled to select the physician
pursuant to Section 4600, the employee shall be entitled to continue
treatment with that physician at the employer's expense in accordance
with this division, notwithstanding Section 4616.2. The employer
shall be required to pay from the date of the initial examination if
the physician's report was submitted within five working days of the
initial examination. If the physician's report was submitted more
than five working days after the initial examination, the employer
and the employee shall not be required to pay for any services prior
to the date the physician's report was submitted.
(3) If the employer objects to the employee's selection of the
physician on the grounds that the physician is not within the medical
provider network used by the employer, and there is a final
determination that the employee was not entitled to select a
physician outside of the medical provider network, the employer shall
have no liability for treatment provided by or at the direction of
that physician or for any consequences of the treatment obtained
outside the network.
(b) (1) Any provider of services provided pursuant to Section
4600, including, but not limited to, physicians, hospitals,
pharmacies, interpreters, copy services, transportation services, and
home health care services, shall submit its request for payment with
an itemization of services provided and the charge for each service,
a copy of all reports showing the services performed, the
prescription or referral from the primary treating physician if the
services were performed by a person other than the primary treating
physician, and any evidence of authorization for the services that
may have been received. Nothing in this section shall prohibit an
employer, insurer, or third-party claims administrator from
establishing, through written agreement, an alternative manual or
electronic request for payment with providers for services provided
pursuant to Section 4600.
(A) Notwithstanding the requirements of this paragraph, a copy of
the prescription shall not be required with a request for payment for
pharmacy services, unless the provider of services has entered into
a written agreement, as provided in this paragraph, that requires a
copy of a prescription for a pharmacy service.
(B) Notwithstanding timely billing and payment rules established
by the Division of Workers' Compensation, any entity submitting a
pharmacy bill for payment, on or after January 1, 2013, and denied
payment for not including a copy of the prescription from the
treating physician, may resubmit those bills for payment until March
31, 2014.
(C) Nothing in this section shall preclude an employer, insurer,
pharmacy benefits manager, or third-party claims administrator from
requesting a copy of the prescription during a review of any records
of prescription drugs that were dispensed by a pharmacy.
(2) Except as provided in subdivision (d) of Section 4603.4, or
under contracts authorized under Section 5307.11, payment for medical
treatment provided or prescribed by the treating physician selected
by the employee or designated by the employer shall be made at
reasonable maximum amounts in the official medical fee schedule,
pursuant to Section 5307.1, in effect on the date of service.
Payments shall be made by the employer with an explanation of review
pursuant to Section 4603.3 within 45 days after receipt of each
separate, itemization of medical services provided, together with any
required reports and any written authorization for services that may
have been received by the physician. If the itemization or a portion
thereof is contested, denied, or considered incomplete, the
physician shall be notified, in the explanation of review, that the
itemization is contested, denied, or considered incomplete, within 30
days after receipt of the itemization by the employer. An
explanation of review that states an itemization is incomplete shall
also state all additional information required to make a decision.
Any properly documented list of services provided and not paid at the
rates then in effect under Section 5307.1 within the 45-day period
shall be paid at the rates then in effect and increased by 15
percent, together with interest at the same rate as judgments in
civil actions retroactive to the date of receipt of the itemization,
unless the employer does both of the following:
(A) Pays the provider at the rates in effect within the 45-day
period.
(B) Advises, in an explanation of review pursuant to Section
4603.3, the physician, or another provider of the items being
contested, the reasons for contesting these items, and the remedies
available to the physician or the other provider if he or she
disagrees. In the case of an itemization that includes services
provided by a hospital, outpatient surgery center, or independent
diagnostic facility, advice that a request has been made for an audit
of the itemization shall satisfy the requirements of this paragraph.
An employer's liability to a physician or another provider under
this section for delayed payments shall not affect its liability to
an employee under Section 5814 or any other provision of this
division.
(3) Notwithstanding paragraph (1), if the employer is a
governmental entity, payment for medical treatment provided or
prescribed by the treating physician selected by the employee or
designated by the employer shall be made within 60 days after receipt
of each separate itemization, together with any required reports and
any written authorization for services that may have been received
by the physician.
(4) Duplicate submissions of medical services itemizations, for
which an explanation of review was previously provided, shall require
no further or additional notification or objection by the employer
to the medical provider and shall not subject the employer to any
additional penalties or interest pursuant to this section for failing
to respond to the duplicate submission. This paragraph shall apply
only to duplicate submissions and does not apply to any other
penalties or interest that may be applicable to the original
submission.
(c) Any interest or increase in compensation paid by an insurer
pursuant to this section shall be treated in the same manner as an
increase in compensation under subdivision (d) of Section 4650 for
the purposes of any classification of risks and premium rates, and
any system of merit rating approved or issued pursuant to Article 2
(commencing with Section 11730) of Chapter 3 of Part 3 of Division 2
of the Insurance Code.
(d) (1) Whenever an employer or insurer employs an individual or
contracts with an entity to conduct a review of an itemization
submitted by a physician or medical provider, the employer or insurer
shall make available to that individual or entity all documentation
submitted together with that itemization by the physician or medical
provider. When an individual or entity conducting an itemization
review determines that additional information or documentation is
necessary to review the itemization, the individual or entity shall
contact the claims administrator or insurer to obtain the necessary
information or documentation that was submitted by the physician or
medical provider pursuant to subdivision (b).
(2) An individual or entity reviewing an itemization of service
submitted by a physician or medical provider shall not alter the
procedure codes listed or recommend reduction of the amount of the
payment unless the documentation submitted by the physician or
medical provider with the itemization of service has been reviewed by
that individual or entity. If the reviewer does not recommend
payment for services as itemized by the physician or medical
provider, the explanation of review shall provide the physician or
medical provider with a specific explanation as to why the reviewer
altered the procedure code or changed other parts of the itemization
and the specific deficiency in the itemization or documentation that
caused the reviewer to conclude that the altered procedure code or
amount recommended for payment more accurately represents the service
performed.
(e) (1) If the provider disputes the amount paid, the provider may
request a second review within 90 days of service of the explanation
of review or an order of the appeals board resolving the threshold
issue as stated in the explanation of review pursuant to paragraph
(5) of subdivision (a) of Section 4603.3. The request for a second
review shall be submitted to the employer on a form prescribed by the
administrative director and shall include all of the following:
(A) The date of the explanation of review and the claim number or
other unique identifying number provided on the explanation of
review.
(B) The item and amount in dispute.
(C) The additional payment requested and the reason therefor.
(D) The additional information provided in response to a request
in the first explanation of review or any other additional
information provided in support of the additional payment requested.
(2) If the only dispute is the amount of payment and the provider
does not request a second review within 90 days, the bill shall be
deemed satisfied and neither the employer nor the employee shall be
liable for any further payment.
(3) Within 14 days of a request for second review, the employer
shall respond with a final written determination on each of the items
or amounts in dispute. Payment of any balance not in dispute shall
be made within 21 days of receipt of the request for second review.
This time limit may be extended by mutual written agreement.
(4) If the provider contests the amount paid, after receipt of the
second review, the provider shall request an independent bill review
as provided for in Section 4603.6.
(f) Except as provided in paragraph (4) of subdivision (e), the
appeals board shall have jurisdiction over disputes arising out of
this subdivision pursuant to Section 5304.
SEC. 2. This act is an urgency statute necessary for the immediate
preservation of the public peace, health, or safety within the
meaning of Article IV of the Constitution and shall go into immediate
effect. The facts constituting the necessity are:
In order to avoid jeopardizing injured workers' access to
medically necessary medications, it is necessary that this bill take
effect immediately.
