New bureaucratic hurdles for opioid reimbursement

New reimbursement rules effective 12/26/14 and how these administrative changes will unnecessarily limit medical treatment.

Access to medical care is the most important benefit under workers’ compensation. Michigan law requires payment of all reasonable and necessary medical treatment. This includes prescription medications.

Opioids are medications that relieve pain. They are commonly prescribed for work injuries and include hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContin, Percocet), and morphine (e.g., Kadian, Avinza).

The Agency has now announced new administrative rules that will prohibit reimbursements for opioid treatment beyond 90 days unless detailed physician reporting requirements and other processes are met. Addressing long-term opioid use and reducing costs for “job providers” are the stated goals.

We are surprised by this announcement considering medical costs in Michigan are already some of the lowest in the Midwest. Additionally, the pure premium rate has dropped nearly 28% in the last 3 years.

More bureaucratic hurdles do nothing but interfere with medical treatment. Doctors will not get paid unless they adhere to specific guidelines that few will understand. The exception process is overly burdensome and requires physicians to spend more time on paperwork than treating patients. Many doctors will simply refuse to treat people under workers’ compensation.

New reimbursement rule for opioids

R 418.101008a Required documentation for reimbursement of treatment for chronic, non-cancer pain with opioids.
Rule 1008a. (1) In order to receive reimbursement for opioid treatment beyond 90 days, the physician seeking reimbursement shall submit a written report to the payer not later than 90 days after the initial opioid prescription fill for chronic pain and every 90 days thereafter. The written report shall include all of the following:
(a) A review and analysis of the relevant prior medical history, including any consultations that have been obtained, and a review of data received from an automated prescription drug monitoring program in the treating jurisdiction, such as the Michigan Automated Prescription System (MAPS), for identification of past history of narcotic use and any concurrent prescriptions.
(b) A summary of conservative care rendered to the worker that focused on increased function and return to work.
(c) A statement on why prior or alternative conservative measures were ineffective or contraindicated.
(d) A statement that the attending physician has considered the results obtained from appropriate industry accepted screening tools to detect factors that may significantly increase the risk of abuse or adverse outcomes including a history of alcohol or other substance abuse.
(e) A treatment plan which includes all of the following:
(i) Overall treatment goals and functional progress.
(ii) Periodic urine drug screens.
(iii) A conscientious effort to reduce pain through the use of non-opioid medications, alternative non-pharmaceutical strategies, or both.
(iv) Consideration of weaning the injured worker from opioid use.
(f) An opioid treatment agreement that has been signed by the worker and the attending physician. This agreement shall be reviewed, updated, and renewed every 6 months. The opioid treatment agreement shall outline the risks and benefits of opioid use, the conditions under which opioids will be prescribed, and the responsibilities of the prescribing physician and the worker.
(2) The provider may bill the additional services required for compliance with these rules utilizing CPT procedure code 99215 for the initial 90 day report and all subsequent follow-up reports at 90-day intervals.
(3) Providers may bill $25.00 utilizing code MPS01 for accessing MAPS or other automated prescription drug monitoring program in the treating jurisdiction.

Michigan Workers Comp Lawyers never charges a fee to evaluate a potential case. Our law firm has represented injured and disabled workers exclusively for more than 35 years. Call (855) 221-2667 for a free consultation today.

Related information:

WCA: Amended Workers’ Compensation Rules will Reduce Opioid Abuse, Lower Medical Costs

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