QUARTERLY NEWS: Workers' Comp Regulatory Update


Oregon WC Division Rulemaking Advisory Committee on PPOs
Darrell DeMoss, General Counsel for MedRisk Inc., has been invited to participate on the Oregon Workers’ Compensation Division Advisory Committee to consider both temporary rules and permanent rules recognizing PPO contracts in Oregon.

Summary of Recent Developments
The Division issued temporary rules effective 7/7/2008 which recognizes PPO contract rates, as well as fee schedule and MCO contract rates as acceptable bases for provider payments.

Key points:

  • These temporary rules will apply to all fee disputes prospectively, regardless of when the services in question were provided; it will not reverse any past fee dispute determinations or agreements.
  • The insurer (or its agent) must provide a copy of the network contract upon Division or provider request.
  • In the event of a fee dispute with the provider, the insurer must notify the provider that he or she may, within 90 days, request an administrative review of the insurer’s decision to deny payment.

Expectations:

  • It is certain that the Division will implement permanent rules. Even the president of the Oregon Medical Association acknowledged that rules addressing PPOs are necessary to reflect current economic reality in the world of health care. It is anticipated that these rules would go into effect no earlier than January 2009.It is expected that the permanent rules will address a number of provider concerns regarding disclosure and fairness issues.
  • MedRisk is providing the Advisory Committee with a sampling of operationally sound regulations from other jurisdictions (For example: Colorado, Ohio and Tennessee laws require PPOs to disclose payer clients and insurance types covered and to provide summaries of material contract terms.)

    Certainties:

    The development of new regulations to protect both payer and provider interests in Oregon will continue to provoke a rash of news articles with varying points of views. In the meantime, MedRisk will continue to be proactive in supporting the development of fair and objective legislations. We will keep you posted.

    Activities to-date:

  • When the Oregon Workers' Compensations Division (WCD) was flooded by fee dispute filings earlier this year, MedRisk sent letters to all its participating providers, asking them to affirm their membership in our network. We then followed up with telephone calls to providers who did not respond.
  • MedRisk sent representatives to Oregon’s WCD to help explain MedRisk's business practices and to clarify any misconceptions.
  • MedRisk was invited to serve on the WCD’s Rulemaking Advisory Committee on PPOs and sent a representative experienced in regulations to participate.