El modelo pedagógico de Formación Basada en Competencias (FBC)

9.4.1

WCRC Review Process

The WCRC receives submissions from the BCRC and from the portal, and performs an independent review of the adequacy of both the medical and prescription drug costs proposed. The WCRC first reviews the case in detail for completeness and accuracy. If errors are found in a submitted case, the submitter is notified.

a) If the case was submitted via the WCMSAP, the submitter will be notified via an

e-mail alert to the address provided during the WCMSAP account setup.

b) If the case was submitted via paper or CD, the submitter will receive a letter via

the postal service.

The WCRC then reviews and evaluates the adequacy of the proposal submitted. Using some or

all of the evaluation tools listed in Appendix 4, the WCRC evaluates the likely need for, and

prices of medical treatments and prescription medications for, the expected duration of the claimant’s life. Based on these findings, the WCRC makes recommendations as to the

disposition of the case, the prescription drugs proposed and costs, treatment plans and costs, and the WCMSA amount. In other words, the WCRC ultimately renders an opinion to CMS as to whether the WCMSA amount proposed is adequate to protect Medicare’s interests.

During its review, the WCRC may need to develop the case for additional information or documentation. If the submitter does not respond to the development letter within the allotted time frame (i.e., 30 days for cases submitted to the BCRC, 10 business days for cases submitted on the WCMSAP), the case is closed for lack of response. If the submitter does respond, but the response is insufficient, another request may be sent to the submitter. If more than one

development request has been sent, the timestamp of the most recent request will be used to calculate the response time frame.

9.4.1.1 Most Frequent Reasons for Development Requests

The five most frequent reasons for development requests by the WCRC:

1. Insufficient or out of date medical records;

2. Insufficient payment histories usually because the records do not provide a breakdown

for medical, indemnity or expenses categories;

3. Failure to address draft/final settlement agreements and court rulings in the cover letter or

elsewhere in the submission;

4. Documents that are referenced in the file are not provided – this usually occurs with court

rulings or settlement documents;

5. References to state statutes or regulations without providing sufficient documentation,

i.e., to which payments the statutes/regulations apply or a copy of the statute or regulation.

9.4.2

WCRC Team Background and Resources Used

All of the WCRC reviewers are licensed healthcare professionals, including registered nurses, physicians, nurse practitioners, and professional counselors. These reviewers also maintain various credentials and certifications, such as Certified Case Managers, Life Care Planners, Certified Coders, Rehabilitation Counselors, and Legal Nurse Consultants. Several are also licensed in the practice of law. The WCRC reviewing staff has knowledge of:

• International Classification of Diseases (ICD)-9, ICD-10, Current Procedural

Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding practices

• Medicare coverage guidelines

• Anatomy, physiology, and pharmacology

• Clinical practice guidelines

• Utilization review standards and practices

• Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations

The WCRC reviewers have many resources to assist them in their daily reviewer responsibilities, including pharmacist, attorneys, the medical director, and certified coders. The reviewers also have access to clinical guidelines, workers’ compensation fee schedules, and Medicare coverage

guidelines to assist with their reviews. See Appendix 4 for a list of specific resources used in

reviews.

9.4.3

WCRC Review Considerations

After the WCRC case reviewer validates that the injury has been accepted as a compensable injury, the next step is to project related future medical care. These considerations are key to review accuracy:

• Are there previous injuries that affect the resolution of the accepted injury?

• Are there underlying medical conditions that will affect the type of future care or the

length of care necessary to bring about the best possible outcome?

• Are there underlying conditions requiring concurrent medications or treatment, but

which are not related specifically to this work injury?

• Are non-treating provider reviews and examinations taking precedence over the

treating providers’ treatment plan?

• Are the medical pricing rules used appropriate for the particular region?

The WCRC team reviews all of the submitted records and attempts to determine the future care required for the individual claimant, taking into consideration the claimant’s specific condition, other comorbidities, and the claimant’s past use of healthcare services. Reviewers use evidence- based rationale for their determinations, taking into account both published guidelines and current peer-reviewed medical literature.

Medical pricing may vary based on injury, age, location, and other factors. Each submission is reviewed independently of other submissions for claimants with the same injury and age. This accounts for any differences in WCMSA amount determination.

For example, a reasonably healthy and active 45-year-old claimant who recently had total knee replacement surgery is likely to require a revision of the surgery (second knee replacement) during his 30-year life expectancy, as the replacement joint wears out. However, another 45- year-old claimant with a recent total knee replacement but who is sedentary and in poor health due to diabetes mellitus and coronary artery disease may not require or be a satisfactory risk for such a revision in the future.

If a claimant might need a revision or replacement surgery in the last 1–3 years of life

expectancy, the decision to include this revision in the WCMSA depends on the type of revision and on the claimant’s overall condition. For example, a claimant in the last 1–3 years of life expectancy is unlikely to have a revision of a total hip replacement surgery, but a spinal cord stimulator (SCS) for pain management would likely be revised if needed.

The WCRC considers both the claimant’s past history of treatment and the recent trending of treatment in determining plans for future treatment frequency. For example, if a claimant was seeing the physician every year initially, but records indicate more frequent visits recently, that will be considered in the determination. There is currently no plan to establish a set of standards for specific conditions.

The WCRC relies on evidence-based guidelines for prescription medication and medical treatment allocations; however, these are guidelines, not rules. The final determination is also based on the claimant’s past use and future recommended treatment as supported by the medical

records and by current peer-reviewed medical literature. See Appendix 4 for a list of resources

the WCRC uses.

The WCRC strives to comply with the laws of the state determined to be the appropriate state of venue. The reviewers research the applicable state regulations and fee schedules. In previous years, the WCRC has priced WCMSAs using the highest fee schedule zone possible within any state that uses fee schedules. Currently the WCRC prices WCMSAs according to the correct region for the state of venue. Hospital fee schedules are currently determined using the

Diagnosis-Related Groups (DRG) payment for a Major Medical Center within the state, and this fee is applied to all locations within the state.

9.4.4

Medical Review

The WCRC follows ten steps in its medical review process. For a list of resources used in the

process, see Appendix 4. The diagram below shows the steps in order, with decision points. The

Figure 9-2: WCRC Medical Review Steps

Start

End WCRC receives

WCMSA proposal

1. Contact & claimant info present & consistent? Consent form signed? Yes 3. DOI & conditions being settled clear? 4. Set-aside amounts & breakdown agree clearly? Yes 5. Pricing method appropriate for jurisdiction or circumstances? Yes Yes 6. WCMSA payment structure clear? No 8. Treatment, payment, pharmacy records

complete, valid & up-to-date?

No

9. Review plan; price appropriate future medical

& pharmacy services Yes Is recommendation to approve WCMSA proposal at proposed amount? 10. Explain decision rationale in response Recommend CMS counter lower or higher

Recommend CMS approve proposal Yes

End Develop for sufficient or

correct information

7. Calculate life expectancy per operating rules; based on standard age

or rated age

Yes 2. TSA clear &

threshold met? Yes

No

Determine correct pricing method