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LWCC Semi-Annual Provider Conference August 23, 2013 New Orleans, LA Wes Hataway, Director, OWCA PowerPoint Presentation
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LWCC Semi-Annual Provider Conference August 23, 2013 New Orleans, LA Wes Hataway, Director, OWCA. “Before my first solo surgery, thinking I wasn’t perfect was my greatest fear. But, knowing I’m not perfect has become my greatest asset.” Doogie Howser, MD. MEDICAL SERVICES. MEDICAL SERVICES.

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slide1

LWCC Semi-Annual Provider Conference

August 23, 2013

New Orleans, LA

Wes Hataway, Director, OWCA

slide4

“Before my first solo surgery, thinking I wasn’t perfect was my greatest fear. But, knowing I’m not perfect has become my greatest asset.”

    • Doogie Howser, MD
medical services
MEDICAL SERVICES
  • Medical Treatment Schedule
  • Effective July, 2011
  • Over 2,000 decisions have been made thus far
  • Goal is to provide efficient, quality care to injured workers.
medical services1
MEDICAL SERVICES
  • Newly implemented Metrics will help us better educate stake holders.
  • Four months of data gathered thus far.
medical services2
MEDICAL SERVICES
  • Minimum requirements for 1009 submission:
    • A completed 1009 form
    • A copy of the 1010 form
    • All information previously submitted to the carrier/SIE
  • Minimum medical information:
    • History provided to level of condition
    • Physical findings/clinical tests
    • Documented functional improvement, if applicable – Test/imaging results – Treatment plan including services being requested along with frequency and duration.
medical services3
MEDICAL SERVICES
  • Common reasons for 1009 rejections:
    • No copy of 1010 submitted (30%)
    • Request deals with compensability (25%)
    • No medical documentation (24%)
    • Not filed within 15 days (22%)
    • Request deals with non-payment of medical bills (11%)
medical services4
MEDICAL SERVICES
  • Common Reasons for upholding denials:
    • Clinical reasons:
      • Clinical findings, natural history of disease, clinical course, diagnostic tests do not correlate to support requested treatment. (25%).
      • Clinical indications have not been met (20%).
      • Positive patient gain, improved pain, or functional improvement not noted (11%).
    • Documentation
      • Documentation does not meet minimum requirement (16%).
hearings division
HEARINGS DIVISION
  • Our goal is to fairly and equitably resolve disputes in a timely manner.
results of sif program 7 1 11 through 6 30 13
RESULTS OF SIF PROGRAM7-1-11 THROUGH 6-30-13
  • Information is for cases closed 7/1/2011 – 6/30/2013.
  •  1,241 persons successfully employed
  • Rehabilitative services were provided to 1,611 disabled workers
  • Average cost per disabled worker was less than $3,000
  • Employees and/or employers in 60 parishes received services
slide28

“One of the most predictable things in life is there will be change. You are better off if you can have a say in the change. But you are ignorant or naïve if you don’t think there will be change, whether you want it to or not.”

  • Julius “Dr. J” Erving
three issues that must be addressed
Three Issues That Must be Addressed
  • Fee Schedule Methodology
  • Statewide Obesity Levels
  • Duration of Benefits
current methodology
Current Methodology
  • §1034.2.  Reimbursement schedule
  • A.  The director of the office of workers' compensation administration shall establish and promulgate a reimbursement schedule for drugs, supplies, hospital care and services, medical and surgical treatment, and any nonmedical treatment recognized by the laws of this state as legal and due under the Workers' Compensation Act and applicable to any person or corporation who renders such care, services, or treatment or provides such drugs or supplies to any person covered by Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950.
  • B.  The director shall adopt, in accordance with the Administrative Procedure Act, rules and regulations necessary to establish and implement a reimbursement schedule for such care, services, treatment, drugs, and supplies.
  • C.(1)  The reimbursement schedule shall include charges limited to the mean of the usual and customary charges for such care, services, treatment, drugs, and supplies.  Any necessary adjustments to the reimbursement schedule adopted and established in accordance with the provisions of this Section may be made annually.
  • (2)  The director shall have the authority to collect the information and data necessary to calculate the reimbursement schedule.  The collection of information and data shall be governed by the following guidelines:
  • (a)  The director shall create a written survey detailing the information requested.
  • (b)  The survey shall be managed by the office of workers' compensation administration in conjunction with an academic institution.
  • (c)  The information requested shall be based upon data at least six months old.
  • (d)  There shall be a minimum of thirty health care providers reporting data upon which each disseminated statistic is based.
  • (e)  No individual health care provider's data shall represent more than twenty-five percent on a weighted basis of each statistic.
  • (f)  Any information disseminated shall be sufficiently aggregated such that it will not allow recipients to identify the prices charged or compensation paid by any particular health care provider.
proposed method
Proposed Method
  • Consistent
  • Predictable
  • Self Updating
  • *Current method is not sustainable, and I want your “say” in the change.
slide35

“Now there are many options available for dangerously underweight individuals like yourself. I recommend a slow steady gorging process combined with assal horizontology” – Dr. Nick

recent headline
Recent Headline…..
  • The heavyweight state: Louisiana ranked most obese in the U. S.
  • -Monroe News Star, August 20, 2013
  • The report found that Louisiana’s adult obesity rate is 34.7 percent.
  • Louisiana’s obesity rate for Baby Boomers (45-to 64-year-olds) is 40 percent and, nationally, rates for Boomers have reached 40 percent in two states (Alabama and Louisiana).
duke university study
Duke University Study
  • Studied over 11,000 employees of the Duke system
  • 7-year study (1997 – 2004)
  • Morbidly obese-medical costs were 6.8 times that of the recommended weight group
  • They were also twice as likely to have a claim
  • Number of lost work days is 13 times higher
john hopkins university study
John Hopkins University Study
  • 2 year study of aluminum plan workers
  • 7,690 workers at 8 plants studied
  • Odds of injury in the morbidly obese group were 2.21 times greater
  • Leg and knee injuries were the most prevalent
ncci study
NCCI Study
  • Data drawn from detailed medical bills of 4 million workers’ compensation claims
  • 1998-2007
  • Look for the ICD-9 code 278 (obesity)
average duration of benefits for injured workers
Average Duration of Benefits for Injured Workers
  • Benefit duration 8-16 weeks longer than in other wage loss states
average duration of benefits
AVERAGE DURATION OF BENEFITS
  • Louisiana – 33 weeks
  • Pennsylvania – 25 weeks
  • North Carolina – 25 weeks
  • Massachusetts – 23 weeks
  • Virginia – 20 weeks
  • Michigan – 17 weeks
  • *WCRI July 2013
slide48

“There's a lot of doctors tell me that I'd better start slowing it down but there's more old drunks than there are old doctors so I guess we better have another round”

  • Willie Nelson - I Gotta Get Drunk Lyrics