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AIG Rule 16 Prezi
Transcript of AIG Rule 16 Prezi
How to contest a request for prior authorization
Procedures for contesting a medical bill for a service that was already performed.
Unreasonable delay in processing payment or denying a request for prior authorization, as determined by the Director or ALJ, may subject the payer to penalties under the Workers' Compensation Act. 16-10(F) and
My Sweet 16: the highs and lows of authorizing medical care
A copy of the Workers' Compensation Rules of Procedure can be found on the Division website at:
Granting prior authorization is a guarantee that the medical service that was authorized will be paid in accordance with the Medical Fee Schedule and Rule 18. 16-9 (A)
When is a physician "required" to request prior authorization? 16-9 (B)
1. When treatment exceeds the recommended limitations provided by the Medical Treatment Guidelines (MTG).
2. When the MTG require prior authorization for that specific service.
3. When the treatment is identified in the Medical Fee Schedule as requiring prior authorization for payment.
4. When a service is not identified in the Medical Fee Schedule.
Prior authorization for a prescribed service may be granted
and without medical review. 16-9 (C)
respond to all
requesting prior authorization within
seven (7) business days
of the provider’s completed request. The duty to respond to a provider's written request applies without regard for who transmitted the request.
How to complete a prior authorization request:
The provider must explain the reasonableness and medical necessity of the service requested and provide relevant supporting medical documentation.
All medical records should be signed by the rendering provider. Electronic signatures are accepted. 16-9 (J)
Presented by Lee + Kinder, LLC 2016
The lack of prior authorization for payment will NOT warrant a denial of payment if the payer later agrees that the treatment that was provided was reasonable and necessary to treat and relieve the effects of the work injury.
Contesting for Non-Medical Reasons
If the payer is contesting a request for prior authorization for non-medical reasons, the payer MUST notify the provider AND parties in writing of the basis of the contest within 7 business days from the receipt of the provider's request. 16-10(A)
The payer MUST attach a certificate of mailing of the written contest to the provider and parties.
Examples of non-medical (administrative) reasons for contesting payment include:
No claim has been filed with the payer;
Compensability has not been established;
The billed service is not related to the admitted injury;
The provider is not authorized to treat;
The insurance coverage is at issue;
Typographical errors are in the bill;
Failure to submit any supporting medical documentation; or
Unrecognized CPT code.
If an ATP requests prior authorization and indicates in writing, including their reasoning with relevant documentation, that they believe the requested treatment is related to the
workers’ compensation claim, the insurer
deny based solely on relatedness without a Rule 16-10(B) medical review. 16-10 (A)
If the payer is contesting a request for prior authorization for medical reasons, the payer must within 7 business days of the completed request:
Have all of the submitted documentation provided by the provider reviewed by a physician who holds a license in the same or similar specialty as would typically manage the medical condition, procedure, or treatment under review.
Furnish the provider and the parties with a written contest that sets forth the following information:
An explanation of the specific medical reasons for the contest,
The name and credentials of the reviewing provider,
A copy of the medical review report,
The specific cite from the MTG exhibits to Rule 17, when applicable,
Identification of the information deemed most likely to influence the reconsideration of the contest when applicable, and
A certificate of mailing to the provider and parties.
Prior Authorization Disputes!
Failure of the payer to timely comply in full with the requirements of Rule 16-10 will be deemed authorization for payment of the requested treatment.
A hearing is requested within the time prescribed for responding (within 7 business days of receipt of the request); and
The requesting provider is notified that the request is being contested and the matter is going to hearing.
Even if the payer complies with all of the Rule 16 procedures and deadlines, they could still get hit with penalties at hearing.
2013 SlimGenics case
The payer MUST send the billing party written notice if contesting payment for non-medical or medical reasons within 30 days of receipt of the bill
If the written notice fails to include the required information, it will be considered defective and will not satisfy the payer's 30-day notice requirement. 16-11(A)(2)
If the payer fails to timely provide the proper reasons for the contest, all bills submitted by a provider will be due and payable according to the Medical Fee Schedule within 30 days after receipt of the bill by the payer. 16-11 (A)(3)
Process for Contesting Payment of a Billed Service for Non-Medical Reasons
If an ATP indicates, in writing with relevant documentation, that they believe the medical service was related to the WC claim, the payer cannot deny based solely on relatedness without a medical review. 16-11(B)(2)
16-11(B)(3): If contested for non-medical reasons, the payer MUST send the billing party a written notice of the contest within 30 days of the receipt of the bill. The notice must include:
Date of service being contested, if dates were on the bill
Acknowledgement of uncontested and paid items submitted on the same bill as contested services
Reference to the bill and each item of the bill being contested
Clear and persuasive reasons for contesting the payment of any item specific to that bill including citing of appropriate statutes, rules, or documents supporting the contest of payment
When contesting payment of a billed services for medical reasons, the payer MUST:
Have the bill reviewed by a physician who is licensed in the same or similar specialty as would typically manage the medical condition, procedure, or treatment under review.
Send the provider and the parties written notice of the contest within 30 days of receipt of the bill.
The information required in 16-11(A)(1)
Date of services being contested
Acknowledgement of specific uncontested and paid items submitted on the same bill as contested services
Reference to the bill and each item being contested
An explanation of the clear and persuasive medical reasons for the decision
The name and credentials of the person performing the medical review
A copy of the medical reviewer's report
The specific cite from the MTG exhibits to Rule 17, if applicable
Identification of the info deemed most likely to influence the reconsideration of the contest, when applicable.
The written notice must include:
Any notice that fails to include the required information set forth in this section is defective and will not satisfy the payer's 30-day notice requirement.
An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the WC Act. In the event the injured worker has directly paid for medical services, the payer shall reimburse the injured worker for the amounts actually paid for authorized services within
after receipt of the bill. If the actual costs exceed the maximum fee allowed by the Medical Fee Schedule, the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee. Each request for a refund shall indicate the service provided and the date of service(s) involved.
Respondents followed the Rule 16 procedures to deny a request for a weight loss program that was recommended as treatment for a work-related knee injury.
ALJ found that Respondents "unreasonably" denied the treatment and this action was reprehensible enough to warrant penalties.
Awarded $50 per day in penalties for a total penalty award of $10,550
ICAO upheld the order finding the weight loss program to be reasonable, necessary, and related and awarded penalties.
Recent changes to wcrp Rule 9-7:
"A party requesting that the Director assess penalties shall file a motion with the Division of WC directed to the Director, which states with specificity the grounds upon which penalties are being sought and includes all evidence upon which the requesting party is basing the request. If no response to the motion is filed, the Director may issue an order to show cause why penalties should not be imposed. Failure to respond to the order to show cause may be deemed a confession of the facts alleged in the motion and a waiver of the right to be heard in response to the request for penalties."
Based on the new language in Rule 9-7, the Director has authority to determine whether penalties are appropriate under WCRP Rule 16-10(F) & 16-11(A)(6).
The Director would then decide whether there was an "unreasonably delay or denial of prior authorization" to warrant the award of penalties up to $1,000 per day.
Parties can be punished by a fine of up to $1,000 per day for each offense.
Be careful when deciding whether to contest and deny a request for medical treatment because the Director or an ALJ may ultimately find that the treatment was reasonable and necessary and impose penalties.
New Rule anticipated to go into effect in April 2016.