IWCC Fee Schedule Updates

The Illinois Workers' Compensation Commission's Medical Fee Advisory Board met on Wednesday for its December meeting.
 
The agenda covered a range of topics, and this first post will cover a couple of those issues.
 

Physician-Dispensed Repackaged Pharmacy

Our previous update covered the changes to the reimbursement for physician-dispensed pharmacy in Illinois.  The final rule should appear in the Illinois Register tomorrow (12/7/12), and the effective date of the reimbursement modification is November 20, 2012. 
 
The Board did clarify that the modification only applies to bills with dates of service/fills on 11/20/12 and later.
 

2013 State Fee Schedule Updates

Glen Boyle, from Health Systems International, LLC, provided a written update regarding both finalized and potential updates to the Illinois state workers' compensation fee schedule.
 
The 2013 annual fee schedule updates and rates are currently scheduled to complete internal review and quality check by December 21, and the new 2013 rates have an anticipated posting date of December 28, 2012.  The annual fee schedule updates are effective on January 1 of each year.
 
In addition to the annual updates, Glen Boyle also reported out on potential methodology changes to update the POCs. 

(The IWCC defines POCs as "when the Commission is unable to calculate a fee for a procedure, there is a default payment provision. From 2/1/06 - 8/31/11, the default is POC76, meaning payment shall be 76% of the charged amount. Effective 9/1/11, all default payments are 53.2% of the charged amount (POC53.2).")
 
From his written report:

a. I suggest utilizing the 2013 Relative Values for Physicians (RVP: we will only be focusing on the professional services fee schedule).  Optum is the publisher of this document, and the Relative Value Units (RVU) are based on actual clinical work performed and the relative values are not related to any Medicare budget issues.  There are RVP values for nearly all CPT codes based on work performed for nearly all medical and surgical fees.  This resource is used by several other states (e.g., Colorado) for the purposes of worker's compensation medical fee schedules.

b. The RVUs are only half of the equation.  Obviously we need a conversion factor so that the RVU can be multiplied to establish a fee schedule level.  To establish the conversion factor I suggest taking known fee schedule amounts and dividing them by the previously mentioned RVU scale.  This process will produce tens of thousands of 'core values' for individual CPT codes.  The basic statistical approach will use correlation analyses using linear regression to validate specific conversion factors.  Specific conversion factors will be established for all regions - further refined into the following categories:

• Surgery
• Radiology
• Pathology and Laboratory
• Medicine
• Evaluation and Management

This approach will establish actual fee schedule amounts for nearly all CPT codes.
 

There was discussion among the Board members on terminology, methodology, etc. regarding these potential changes.  These changes will either be discussed at the next scheduled Medical Fee Advisory Board meeting (3/13/13) or at a meeting specifically scheduled to discuss these issues (TBD).