SB 537 — Workers' compensation: treatment and disability.

Summary

Existing law establishes a workers' compensation system, administered by the Administrative Director of the Division of Workers' Compensation, to compensate an employee for injuries sustained in the course of employment. Existing law requires the employer to provide medical, surgical, chiropractic, acupuncture, and hospital treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods. Existing law defines a "physician" for purposes of the workers' compensation laws to include physicians and surgeons, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners licensed by state law and within the scope of their practice. Existing law also requires the administrative director to post certain information on the division's internet website. This bill would require the administrative director to issue a report to the Legislature, on or before January 1, 2023, comparing potential payment alternatives for providers to the official medical fee schedule. The bill would also require, on or before January 1, 2024, and annually thereafter, the administrative director to publish on the division's internet website provider utilization data for physicians, as defined above, who treated 10 or more injured workers during the 12 months before July 1 of the previous year, including the number of injured workers treated by the physician and the number of utilization review decisions that resulted in a modification or denial of a request for authorization of medical treatment based upon a determination of medical necessity. The bill would authorize the administrative director to withhold data if deemed necessary to protect patient privacy. Existing law prohibits a person or public or private entity not a party to a claim for workers' compensation benefits from obtaining individually identifiable information obtained or maintained by the division regarding that claim, except as provided. Existing law requires the administrative director to develop a cost-efficient workers' compensation information system and authorizes the administrative director to use individually identifiable information for purposes of creating and maintaining that system. This bill would require the administrative director to use individually identifiable information for purposes of creating provider medical utilization data as described above. Existing law requires a workers' compensation insurer, third-party administrator, or other entity that requires, or pursuant to regulation requires, a treating physician to obtain either utilization review or prior authorization in order to diagnose or treat injuries or diseases compensable pursuant to specified law, to ensure the availability of those services from 9 a.m. to 5:30 p.m. Pacific standard time of each normal business day. Existing law defines a normal business day for these purposes to exclude Saturdays, under specified circumstances, Sundays, and certain holidays, as described. This bill would revise the definition of a normal business day for these purposes to specifically exclude every Saturday, Sunday, and specified other holidays. The bill would also make technical changes. Existing law authorizes an insurer, employer, or entity that provides physician network services to establish or modify a medical provider network for providing medical treatment to injured employees and imposes various duties upon the insurer, employer, or entity in connection with the network. Existing law requires every medical provider network to post on its internet website a roster of all treating physicians in the medical provider network and requires every network to provide to the administrative director the internet website address of the network and of its roster of treating physicians. Existing law requires the administrative director to adopt a medical treatment utilization schedule. Existing law authorizes the administrative director to investigate complaints and to conduct random reviews of approved medical provider networks. This bill would, commencing July 1, 2021, require every medical provider network to post on its internet website a roster of participating providers and to provide to the administrative director the internet website address of the network and of its roster of participating providers. The bill would revise the authority of the administrative director by giving the administrative director authority and discretion to investigate complaints, conduct random reviews, and take enforcement action against medical provider networks, an entity that provides ancillary services, as defined, or an entity providing services for or on behalf of the medical provider network or its providers, regarding noncompliance with, among others, the internet address and roster requirements imposed on those networks. Existing law requires a physician providing treatment to send a request for authorization for medical treatment to the claims administrator. Existing law requires a provider's itemized request for payment to be submitted to an employer within 12 months of the date of service or within 12 months of the date of discharge for inpatient facility services for services provided on or after January 1, 2017. This bill would prohibit an entity other than the requesting physician or provider from altering or amending a request for authorization for medical treatment prior to the submission of the request to the claims administrator, and would state that this provision is declaratory of existing law. The bill would require an itemized request for payment for services to be submitted to an employer with the physician's or provider's national provider identifier number. Existing law requires the administrative director to adopt a schedule for payment of home health care services that are not covered by a Medicare fee schedule and are not otherwise covered by the official medical fee schedule described above. Existing law authorizes a health care provider or licensed health facility and a contracting agent, employer, or carrier to contract for reimbursement rates different from those in the fee schedule. This bill, on and after July 1, 2021, would require an entity that provides physician or ancillary network service to provide a payor with a written disclosure of the reimbursement amount paid to the provider with a rate sheet if a contracted reimbursement rate is more than 20% below the official medical fee schedule, as specified. The bill would authorize an entity that provides physician or ancillary network services to require a payor to sign a nondisclosure agreement before providing that disclosure.

Bill Text

• Chaptered 10/08/19 - Chaptered Current pdf October 08, 2019
• Enrolled 09/16/19 - Enrolled pdf September 16, 2019
• Amended 09/06/19 - Amended Assembly pdf September 06, 2019
• Amended 09/03/19 - Amended Assembly pdf September 03, 2019
• Amended 08/13/19 - Amended Assembly pdf August 13, 2019
• Amended 07/02/19 - Amended Assembly pdf July 02, 2019
• Amended 04/11/19 - Amended Senate pdf April 11, 2019
• Amended 03/27/19 - Amended Senate pdf March 27, 2019
• Introduced 02/21/19 - Introduced pdf February 21, 2019
• SB537 View text html

Action History

1. October 08, 2019

   Chaptered by Secretary of State. Chapter 647, Statutes of 2019.

2. October 08, 2019

   Approved by the Governor.

3. September 19, 2019

   Enrolled and presented to the Governor at 3 p.m.

4. September 12, 2019

   Assembly amendments concurred in. (Ayes 40. Noes 0. Page 2895.) Ordered to engrossing and enrolling.

5. September 10, 2019

   In Senate. Concurrence in Assembly amendments pending.

6. September 10, 2019

   Read third time. Passed. (Ayes 78. Noes 0. Page 3338.) Ordered to the Senate.

7. September 06, 2019

   Ordered to third reading.

8. September 06, 2019

   Read third time and amended.

9. September 04, 2019

   Read second time. Ordered to third reading.

10. September 03, 2019

    Read second time and amended. Ordered to second reading.

11. August 30, 2019

    From committee: Do pass as amended. (Ayes 18. Noes 0.) (August 30).

12. August 21, 2019

    August 21 set for first hearing. Placed on APPR. suspense file.

13. August 13, 2019

    Read second time and amended. Re-referred to Com. on APPR.

14. August 12, 2019

    (Received at desk July 17 pursuant to JR 61(a)(10)).

15. August 12, 2019

    From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 14. Noes 0.) (July 10).

16. July 02, 2019

    From committee with author's amendments. Read second time and amended. Re-referred to Com. on INS.

17. May 30, 2019

    Referred to Com. on INS.

18. May 22, 2019

    In Assembly. Read first time. Held at Desk.

19. May 21, 2019

    Read third time. Passed. (Ayes 38. Noes 0. Page 1189.) Ordered to the Assembly.

20. May 16, 2019

    Read second time. Ordered to third reading.

21. May 16, 2019

    From committee: Do pass. (Ayes 5. Noes 0. Page 1102.) (May 16).

22. May 10, 2019

    Set for hearing May 16.

23. April 29, 2019

    April 29 hearing: Placed on APPR. suspense file.

24. April 18, 2019

    Set for hearing April 29.

25. April 11, 2019

    Read second time and amended. Re-referred to Com. on APPR.

26. April 11, 2019

    From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 4. Noes 0. Page 654.) (April 10).

27. April 05, 2019

    Set for hearing April 10.

28. April 03, 2019

    Re-referred to Com. on L., P.E. & R.

29. March 27, 2019

    From committee with author's amendments. Read second time and amended. Re-referred to Com. on RLS.

30. March 07, 2019

    Referred to Com. on RLS.

31. February 22, 2019

    From printer. May be acted upon on or after March 24.

32. February 21, 2019

    Introduced. Read first time. To Com. on RLS. for assignment. To print.

Sponsors

• Hill · Primary

Votes

Subjects