11-29-2019; Retirement of IL Senate President Cullerton; Temporary Transitional Work Ruled Effective in IL WC; New Medicare Reference Guide and more

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Synopsis: Retirement of IL State Senate President John Cullerton.

 

Editor’s comment: The defense team at Keefe, Campbell, Biery & Associates wants to salute the coming retirement of a great Illinois leader, John Cullerton. John is a quiet and strong legislator. John  He will be greatly missed by the IL WC community. He was a quiet force that kept the system intact over his 40+ year career. We hope he hangs around a little to continue giving great advice to the legislators he is leaving behind.

 

 

Synopsis: Temporary Transitional Duty Works Again in IL WC—Will It Work On Your WC Claims?

 

Editor’s comment: In Stegan v. Reladyne LLC, 27 ILWCLB 161 (Ill. W.C. Comm. 2019) Petitioner sustained a work-related injury to his shoulder that resulted in permanent light duty work restrictions felt to be “below” his prior occupation as a forklift operator.

 

Respondent Reladyne’s claims team hired Transitional Work Solutions to help Claimant find work within his restrictions.

 

Transitional Work Solutions placed Petitioner with Habitat for Humanity Restore in a charitable position within his restrictions, but Petitioner refused the position without any particular reason and did not show up for that work. Regular hourly wages were to be paid by the claims handler during all times Claimant showed up to Habitat for Humanity Restore—when Claimant didn’t show for the charity work, lost time benefits were terminated.

 

When the dispute came to hearing, the IL WC Arbitrator found Respondent Reladyne liable for temporary total disability benefits because of a controversial view the IL WC Act does not require Petitioner to accept an unpaid position from an entity other than Respondent.

 

The IL WC Commission reversed the Arbitrator and denied wage replacement benefits, noting the charitable position was not unpaid. Respondent would have remained his employer and maintained control with his normal pay and other benefits. The only change to his employment would be where he was reporting to work and his work activities.

 

The Commission found the Petitioner had no justification for his refusal to participate in the return to work program and ruled Respondent was not liable for TTD benefits.

 

This concept is called “temporary transitional duty” in other states. I looked up Transitional Work Solutions and they can be reached at their website at https://www.twsworks.com/ Whether you use them or some other vendor, I strongly recommend this concept for all IL and U.S. employers and insurance carriers.

 

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Synopsis: The Feds issue a New and Updated WCMSA Reference Guide for Medicare’s Handling of this Complex Process.

 

Editor’s comment: In October, CMS released a revised Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide. The updated guide is version 3.0, dated October 10, 2019, and can be found at this link: Guide.  As with other versions of the guide, updates are found in Section 1.1.  Of the updates, there are two of great significance that will likely have an immediate impact on your claims:

  1. Required language for the CMS Consent to Release has been amended to include that a beneficiary understands the intent, process, and administration of WCMSAs. This language must be included on all release forms starting April 1, 2020; and

  2. The Amended Review timeframe has been extended from 1-4 years to 1-6 years after a CMS approval has been issued.

Changes to Required Language on CMS Release Form

The Consent to Release form is Claimant’s signed authorization for CMS, its agents and/or contractors (the Workers’ Compensation Review Contractor (WCRC) specifically) to discuss a claimant’s case/medical condition with the parties identified on the authorization.  As of April 1, 2020, all forms must include language indicating the beneficiary reviewed the WCMSA submission package and understands the WCMSA intent, submission process, and associated WCMSA administration.

The section of the consent form, referencing understanding of the WCMSA, must include at least the beneficiary’s initials to indicate their validation. The new reference guide includes a template CMS release form which can be referenced for use. 

Amended Review Opportunity Expanded from Four to Six Years

CMS first introduced the amended review opportunity in 2017, allowing for an additional review of cases which have not settled, and reflect a significant change in treatment based upon new medical records/information. This additional review was limited to a period of 1-4 years from the date of the approval letter.  The expansion of the eligible amended review criteria is significant, allowing for the review of cases which have not settled and now fall in line with the following criteria:

  • CMS has issued a conditional approval within at least 12, but no more than 72 months prior;

  • A prior Amended Review has not been submitted;

  • The case has not yet settled as of the date of the request for re-review; and

  • Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

This is a nice change to the Amended Review process, which should be perceived as an opportunity to settle cases which have remained unresolved.  With the expansion to six years, parties now have additional time by which to utilize this process. While this expansion still limits the process to a subset of cases, it is nonetheless an opportunity to obtain an updated CMS approval to reflect a claimant’s current medical status.  Of note, MEDVAL’s clients that are taking advantage of this opportunity are seeing significant reductions in MSAs and are able to settle previously “un-settleable” cases.

WCMSA Administration Updates

·         “Death of a Claimant” information has been updated and standardized with the Self Administration Toolkit;

·         CMS’ expectations for administration of WCMSA funds when “frequently abused drugs” are prescribed for a claimant have been clarified, with a policy and guidance link;

·         Updates include a newly created professional administrator role/electronic attestation enhancement in the portal.

Pricing of Hospital Fee Schedules Clarified

CMS clarified how pricing of hospital fees is derived. CMS notes hospital fees are priced based upon “the Diagnosis-Related groups payment for the median Major Medical Center within the appropriate fee jurisdiction for the pricing ZIP code, unless otherwise defined by law.” Of note, CMS has been utilizing this pricing for years.

Updated Life Table Link

The Life Table link has been updated to reflect use of the 2016 life table.

Keefe, Campbell, Biery & Associates has two certified Medicare specialists—please send an email or call with questions or concerns about this complex Federal morass!