4123-6-21 Payment for outpatient medication.

 

 

 

NOTICE OF PUBLIC HEARING

 

The Ohio Bureau of Workers' Compensation will hold a public hearing on Monday, June 13, 2011, at 1:00 p.m., in Room 1, Level 2, 30 West Spring Street, Columbus, Ohio 43215, to consider the following:

 

Amendment of the following rules for the purposes as shown below:

 

4123-6-16.2 Medical treatment reimbursement requests.

 

Some of the major substantive changes proposed for the medical treatment reimbursement requests rule are as follows:

 

·         Adds a definition of "eligible treating provider" to the rule;

·         Eliminates the reference to the timeframe for inactive claims being 13 months and replace it with a cross-reference to claim reactivation rule OAC 4123-3-15;

·         Medical treatment reimbursement requests submitted by a physical therapist or occupational therapist must be accompanied by a prescription and that approval of such requests shall be valid for no longer than 30 days;

·         Provides that approval of all other medical treatment reimbursement requests shall be valid for no longer than six months;

·         Adds three more circumstances under which an MCO may dismiss a medical treatment reimbursement request without prejudice to those currently in the rule:

·         The underlying claim has been disallowed or dismissed in its entirety, or the only allowances in the underlying claim are for substantial aggravation of a pre- existing condition, and the conditions have been determined in a final administrative or judicial determination to be in a non-payable status;

·         The services or supplies being requested are never covered by the bureau pursuant to other bureau statutes or rules;

·         The MCO has requested supporting medical documentation from the submitting physician of record or eligible treating provider necessary to the MCO's evaluation and determination, and such documentation is not provided to the MCO.

 

4123-6-21    Payment for outpatient medication.

4123-6-21.1 Payment for outpatient medication by self-insuring employer.

 

BWC proposes amending its outpatient medication rule, OAC 4123-6-21, to institute a clinical focus to the Bureau's method of operation. These amendments address the clinical issues of patient safety by giving the Bureau and its pharmacy department more control over how medications are reimbursed. In addition, the amendments proposed define the qualifications required of BWC's pharmacy program director to be consistent with those recently adopted in OAC 4123-6-21.2. The overarching concern of the outpatient medication rule can be found in paragraph (A), which allows the Bureau to

 

 

 

 

 

 

deny a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for treatment of an allowed condition in a claim.

BWC proposes to revise rule OAC 4123-6-21 by introducing a clinical perspective that is intended to improve outcomes for injured workers. This increased focus on the treatment being provided to an injured worker will be a part of the determination of whether or not a drug or class of therapeutic drugs is reasonably related to or medically necessary for treatment of an allowed condition in a claim.

Since self-insuring employers are required to pay benefits equal to or greater than BWC, where applicable BWC is proposing to make changes parallel to those proposed in OAC 4123-6-21 in the Chapter 4123-6 self-insuring employers' outpatient medication rule, OAC 4123-6-21.1.

4123-18-09 Vocational rehabilitation provider fee schedule.

Some of the major substantive changes proposed for the vocational rehabilitation fee schedule include:

·         Fee increases;

·         Elimination of services;

·         New local codes;

·         Changes in definitions; and,

·         Changes in units of service.

The full and complete text of the proposed rules is available at the Register of Ohio (http://www.registerofohio.state.oh.us) and is on file in the office of the Secretary of State (180 East Broad Street, 15th Floor, Columbus, Ohio), the Legislative  Service Commission (77 South High Street, 9th Floor, Columbus, Ohio), the office of the Joint Committee on Agency Rule Review (77 South High Street, Concourse Level, Columbus, Ohio), the Bureau of Workers' Compensation, Legal Operations (30 West Spring Street, 26th Floor, Columbus, Ohio), the Bureau of Workers' Compensation (30 West Spring Street, Columbus, Ohio, 1st Floor, Hearing Rooms), and all service offices of the Bureau.

All interested parties will be given an opportunity to be heard. Any interested party unable to attend the public hearing may submit written comments to the undersigned prior to the public hearing at [e-mail].

THE OHIO BUREAU OF WORKERS' COMPENSATION

Tom Sico

Assistant General Counsel, BWC 30 West Spring Street, L-26 Columbus, Ohio 43215-2256

[phone]