1-9-12; We thought we had great news to report on IL WC PPPs but, sadly, we probably have a couple more months to go. We did see FAQ’s from the DOI about IL WC PPP’s—see below

This past Tuesday, letters from the Illinois Department of Insurance sent on December 30, 2011 were received by three approved WC PPP providers confirming they were “finally approved.” We assumed final approval meant rock-and-roll, good-to-go, hasta-la-vista baby!!! Instead, we learned it was yet another administrative teaser. At present, our regulators and stat-rats continue to finalize the PPP legislation designed to give Illinois employers that ability to direct medical care and otherwise limit choice of care.

The three PPP administrators approved so far are listed on the Illinois Department of Insurance website and are CorVel Healthcare, Coventry Health Care Workers’ Compensation Inc and HFN, Inc. The preferred provider program was authorized as part of House Bill 1698, the workers’ compensation overhaul legislation passed by legislators in May and signed into law in June by Gov. Quinn.

A PPP is a group of medical providers that has been approved by the employer to treat workers for their injuries. Employers may hire an administrator for the PPP, and the Department of Insurance must approve PPP applications by employers and administrators. Under current law that will not change unless and until all rules and PPP’s are in effect, an injured worker was entitled to choose two doctors for treatment, and to receive treatment from any medical providers to whom his doctor referred him.

Under HB 1698, if an employer is not enrolled in an approved PPP, an injured worker still will be able to treat with his choice of two doctors and all referrals.

Illinois Employers who are enrolled in IL WC PPPs may direct the injured worker's care to medical providers in the network. An employee may opt out of the network at any time upon notice to the employer. However, if an employee does opt out, he is limited to one choice of physician and any referrals by that physician.

An employer using a PPP must provide notice of the availability of the PPP to its workers on a form promulgated by the Illinois Workers’ Compensation Commission. If you need the link, send a reply—it has not yet been linked to the IWCC’s forms section of their website.

Getting the rules in place will require review by the state Legislature's Joint Committee on Administrative Rules (JCAR), which will take at least 150 days after the rules are finalized. The IL Department of Insurance managers have confirmed the proposed rules should be submitted to the committee this month. JCAR will review the rules and then schedule a public comment period.

This is from the Illinois Department of Insurance website - Frequently Asked Questions Regarding Workers’ Compensation Preferred Provider Programs (WC PPPs)

1. What are the requirements for obtaining approval of the WC PPP?

Current PPP registration would require each applicant to meet the provisions of:

a. 215 ILCS 5/370 k (Registration); b. 215 ILCS 5/370l (Fiduciary and bonding – where applicable); c. 215 ILCS 5/370m (Program requirements); d. 820 ILCS 305/8.1a(a)(1) (Occupational and non-occupational network adequacy); e. 820 ILCS 305/8.1a(a)(2) (Physician and provider network adequacy appropriate for treating injured workers); f. 820 ILCS 305/8.1a(a)(4) (Prohibition on inappropriate economic credentialing); g. 820 ILCS 305/8.1a(a)(5) (Prohibition against unreasonable discrimination in terms of noninstitutional provider agreements); h. 820 ILCS 305/8.1a(b) (Description of any economic evaluation policies and procedures); and i. Applicable sections of 50 IAC 2051 which implement the above referenced statutory references.

2. Are the networks composed of doctors and facilities?

Yes. WC PPP networks may also be specialty networks.

3. Will an employer be allowed to select doctors from a specific group, or will they be forced to select all doctors from a given group when choosing that group

To the extent that an employer desires to directly contract with individual providers (Section 8.1a), they may establish terms and conditions that must be met as long as such terms and conditions do not unreasonably discriminate against or among noninstitutional providers (Section 8.1a(a)(5)).

To the extent that an employer desires to directly contract with a WC PPP to use a “nested network” (a network which is a smaller component of the whole and such restricted network has been approved by the Department), the employer would also have that statutory flexibility.

4. Do specialty networks, such as pharmacy and physical therapy fall within the WC PPP? How will these networks be handled?

Specialty networks fall within the WC PPP and will be handled in the same manner as other providers.

5. Will current occupational medicine providers be required to join a WC PPP in order to qualify as a preferred provider?

Yes.

6. What are the requirements for employee notification of the WC PPP? Is the DOI working with the Commission to establish this form?

These requirements are stated in 820 ILCS 305/8(4)(A). The DOI is cooperating with the IWCC in developing the form to be used.

7. What confidentiality restrictions will apply to required WC PPP filings?

PPP filing documents will be handled similarly to other provider network filings with regard to both subpoenaed material and material requested under a Freedom of Information Act request. Section 8.1a(b)(1) of the Workers’ Compensation Act requires the Director not to publicly disclose any filed information determined to be confidential, proprietary, or a trade secret.

8. Will provider reimbursement rates be held confidential?

Yes.

9. Will a WC PPP administrator be notified when a request is made for a copy of their filing?

Not as a routine matter. Such a request would fall under FOIA standards and requirements. (5 ILCS 140/1).

10. How will the Department handle WC PPP renewals?

The procedure is outlined in 50 IAC 2051.240 – Registration, Renewals, and Appeals.

11. Will an employer have to register as a WC PPP Administrator if they utilize more than one WC PPP?

Yes, if they are the entity which directly contracts with multiple WC PPPs.

12. Will WC PPPs have additional or alternative registration, fiduciary or bonding requirements than those in law and regulation

Not currently.

13. What late payment standards will apply, given that there is one standard in the Insurance Code and another in the Workers’ Compensation Act?

Standard rules of legislative construction will apply to resolve any apparent conflict.

14. Section 370m(2) requires that notice be given to beneficiaries of “any limitations or exclusions” to coverage. Must notice be given of all possible defenses under the WC Act?

No. Disclosures should provide notice to beneficiaries of possible financial liability if their WC claim is determined to be non-compensable.

15. Section 370m(4) requires that notice be given of a complaint procedure. Will there be a required DOI complaint procedure?

Notice must be given to beneficiaries of any complaint procedure, if one exists.

16. Section 370m(5) requires disclosure of “deductible and coinsurance” amounts. These don’t apply in WC, what should we do?

If there are none, then there are none to disclose.

17. What will be the parameters used by the Department to define an “adequate number of occupational and non-occupational providers”, an “adequate number and type of physicians”, “availability and accessibility of care”?

The Department of Insurance will solicit comments from interested parties and promulgate best practice standards.

18. 50 IAC 2051.280(b) requires that an employee be charged no more in out-of-pocket expenses in the event of necessary out of network care. Will this be applied to WC PPPs?

Yes. Employees should not be penalized for networks that would otherwise be inadequate.

We thank the reader who sent us most of the information above. KC&A has at least one client who is seeking assistance and counseling in forming their own approved PPP network. If you know of someone who could assist us in navigating this minefield, please send a reply. We appreciate your thoughts and comments. Please do not hesitate to post them on our award-winning blog.

1-3-12; NEXT WEEK!!!! NEXT WEEK!!!! NEXT WEEK!!!! NEXT WEEK!!!! NEXT WEEK!!!! NEXT WEEK!!!!

2011 Amendments and the Impact on Vocational Rehabilitation

Space is limited. Reserve your Webinar seat now!

(Texas Adjuster CEUs and CCMC credits have been applied for.)

Date:        Tuesday, January 10th, 2012

Time:     11:00AM - 12:00 PM CDT

Woodlake Medical Management and Encore Unlimited are excited to sponsor this free educational webinar. In this webinar, Gene Keefe of Keefe, Campbell & Associates and Roberta Bandes of Encore Unlimited will review the 2011 Amendments and discuss the impact they will have on vocational rehabilitation going forward. Claims adjusters, claims managers and risk managers/employers concerned about the costs associated with wage differentials and permanent totals in the state of Illinois are strongly encouraged to attend. If you have any specific questions about vocational rehabilitation or the 2011 Amendments that you would like to have addressed in this presentation, please feel free to email them to chris@woodlakemedical.com prior to the webinar. 

There is limited capacity for this webinar, so please register today!

Registration Link: https://www1.gotomeeting.com/register/383015424

Sponsors:

In 1994 Woodlake Medical Management was created with one simple concept: To give you quick IME appointments scheduled with a wide variety of doctors, while efficiently delivering well-explained, definitive medical opinions. We are a group of dedicated, friendly people who strive to consistently treat you so well that you look forward to doing business with us.

Encore Unlimited is an established disability management company providing a full complement of case management services to our customers in Wisconsin, Iowa, Illinois, Minnesota, New Mexico, Upper Peninsula of Michigan and Arizona. While we opened our doors for business in July 2001, our staff, both management and field case managers, have been working in this field for the past twenty years and have well developed relationships with most of the primary insurance companies, self-insured employers and the medical community.

1-3-12; Drug-abusing former police sergeant sadly loses his job and the reviewing courts affirm the termination was appropriate

Our Illinois Appellate Court confirmed the longstanding rule factual findings in administrative decisions should only be reversed if against the manifest weight of the evidence. In Gorski v. Board of Fire and Police Commissioners of the City of Woodstock, 2011 IL App 2d 100808 (December 22, 2011), the Appellate Court indicated the Circuit Court properly affirmed the Board of Fire and Police Commissioners' termination of a former city police sergeant for abuse of prescription narcotic drugs as it was not against the manifest weight standard since sufficient evidence showed the sergeant violated his return-to-work agreement as well as violating an agreement with his doctors to not abuse narcotics and to not use them on duty. It was further noted the former sergeant also failed to sufficiently refute the prima facie case.

Procedurally, the initial hearing before the Board of Fire and Police Commissioners of Woodstock (Board) resulted in a directed finding in favor of Gorski—however thereafter Woodstock Chief Lowen filed a complaint for administrative review in the Circuit Court, the Circuit Court reversed the Board’s decision and remanded—this resulted in the “termination” decision from which these appeals arose. At that first hearing, there were multiple confirmations former sergeant Gorski sought prescription drugs from multiple sources as well as used same while on duty and failed multiple drug screens as well as failing to comply with a return to work agreement and violated an agreement with the Illinois Pain Institute regarding his treatment with Suboxone because of “his overall pattern of overlapping use and abuse of prescription narcotic drugs.”

Issues had arisen according to Chief Lowen when he testified on February 13, 2006, he met with Gorski and told him he was concerned Gorski was abusing prescription drugs, told Gorski it was not appropriate to take Vicodin while performing his duties as a sworn police officer and referred Gorski to the employee assistance program. Chief Lowen testified nearly a year later, on April 12, 2007, he met with Gorski to discuss Gorski’s “sick record” and use of prescription drugs. Chief Lowen required Gorski to submit to a drug urine screen which came back positive. Gorski told Chief Lowen he knew the screen would come back positive because he had received medication at an emergency room from a Dr. Gallant. Chief Lowen placed Gorski on paid administrative leave so Gorski could “seek counseling for his drug use and get things straightened out.” Chief Lowen told Gorski before he could return to work he would have to pass a fit-for-duty test, which included a urine screen. Chief Lowen received a letter from Dr. Martin Fortier clearing Gorski to work as of June 5, 2007 and indicated Gorski had been off pain medication for at least 10 days. Chief Lowen also testified on June 7, 2007, he and Gorski scheduled the fit-for-duty test for June 11, 2007 and his urine screen came back positive for hydromorphone. Gorski told Chief Lowen, before the urine screen, he had taken two Vicodin pills left over from Dr. Fortier’s prescription. He also told Chief Lowen, after the urine screen, he had taken two more Vicodin pills from the same prescription.

Chief Lowen testified on June 18, 2007, he presented Gorski with a return-to-work agreement that prohibited him from using controlled substances other than those prescribed by a physician; required him to use any controlled substance only in a manner consistent with the prescription set forth by the prescribing physician; required him to provide the police department with documentation concerning any prescribed medication indicating the medication would not interfere with his duties as a police officer; and required him to submit to drug testing within one hour of any such request. Chief Lowen ordered Gorski to submit to a urine screen on July 3, 2007, but he did not submit to the screen because of illness. On July 11, 2007, at Chief Lowen’s request, Gorski submitted to a urine screen, which came back negative. On July 17, 2007, Gorski signed the return-to-work agreement, and he returned to work the following day. On July 18, his first day back to work, he submitted to a urine screen; the results would take nine days. Chief Lowen testified, on the way to provide the sample, Gorski said he was not taking Vicodin and he would not take it. As proof, Gorski gave Chief Lowen an empty prescription bottle from Dr. Fortier. Gorski submitted to another urine screen on July 26. The following day, Gorski’s July 18 urine screen came back positive. On August 9, the July 26 urine screen came back positive. Chief Lowen never received documentation from a physician that Gorski’s medications would not interfere with his duties as a police officer.

Chief Lowen testified Gorski told him the drugs he took before the July 18 positive screen came from Dr. Fortier and the drugs he took before the July 26 positive screen came from his father, Dr. Gorski. Gorski told Chief Lowen his father gave him the drugs without a prescription. Chief Lowen testified the integrity of the City of Woodstock was adversely affected by Gorski’s failure to refrain from using prescription drugs and he recommended Gorski be terminated—at the remand hearing, termination was the decision of the Board.

To confirm, former Sergeant Gorski failed drug screens on:

·         April 6, 2006—positive for hydrocodone and hydromorphone

·         April 12, 2007—positive for hydrocodone and hydromorphone

·         June 11, 2007—positive for hydromorphone

·         July 18, 2007—positive for oxymorphone

·         July 26, 2007—positive for hydrocodone, hydromorphone, oxycodone, and oxymorphone

Initially the Appellate Court noted Gorski failed to recognize, in administrative review proceedings, they review the administrative agency's decision and not the decision of the Circuit Court. The Appellate Court noted they would review both findings of the administrative agency since the initial directed finding which was reversed on remand was not a final decision. The Appellate Court noted a motion for a directed finding must be denied if the plaintiff has presented a prima facie case. They also noted the manifest weight standard applied in the determination of whether a decision should be reversed by the Circuit Court. The Appellate Court found the record revealed Chief Lowen established a prima facie case Gorski abused prescription narcotic drugs and, in doing so, he violated the rules and regulations of the police department, the return-to-work agreement, and agreements he had with Dr. Rana at the Institute and with Dr. Purdy regarding his drug dependence treatment with Suboxone. The evidence established Gorski violated agreements four times. The Appellate Court further noted nothing in the record indicates Gorski’s misconduct was substantially related to his back injury. In violation of agreements with the police department and doctors, Gorski obtained by deceptive means multiple prescriptions for narcotic medications from multiple doctors and took these medications while on duty. He failed to provide the police department with the required documentation he was taking medication prescribed by physicians and the medication would not affect his ability to perform his duties.

Finally while Gorski argued the termination on the second Board decision was a result of the Circuit Court’s first decision, which was against the manifest weight of the evidence standard, he not only failed to recognize the Appellate Court was not bound by the Circuit Court's decisions, he also failed to cite authorities or pages of the record relied upon. The Appellate Court determined he had forfeited that argument for not setting forth a factual bases for such with citation to the record.

There are several takeaways from this ruling, including the important distinction that a decision is not appealable until it is final. It is also important to note the Appellate Court demands very specific and detailed guidelines for creating and arguing your appeals. In their comments in this case, they made it very clear they will not sift the record to attempt to determine if arguments find support in the record if the drafting party does not cite the record for their contentions. Finally, this case is a good example of why a party should present all applicable evidence they have in support of their case as the bulk of the evidence presented provided the support for the affirmation of the decision. Maybe most important, it is the belief of this commentator that individuals in a position of public safety should be held to a high standard. In this case it appears the appropriate steps were taken to attempt to allow the individual to help himself and his inability to appropriately do so, as well as his attempts to avoid culpability for his own actions, resulted in a termination which may not have been acceptable to the individual but was appropriate to protect the public at large.