This letter is to address the impact of Senate Bill 1160 (or SB1160) pertaining to self-insureds, TPA’s or third-party-administrators, employers, and utilization review organizations across California. On September 30, 2016, SB1160 was signed by Governor Jerry Brown, which is set for implementation beginning the first of January in 2018. The result of this bill will have a significant legislative impact on the way managed care data is delivered within the workers’ compensation system in California.
All claims administrators will be held accountable to have an electronic system in place for mandatory reporting of documents (to the Department of Workers’ Compensation or DWC) related to EVERY* utilization review that is performed. The DWC also states “SB1160 additionally reduces review requirements in the first 30 days following a work-related injury” (dir.ca.gov). This indicates that systems processing the requests should allow for client rules to match the DWC requirements including pre-conditional rules, maximum treatments allowed, max spend limits for items like Durable Medical Equipment or DME, and whatever other items the DWC may consider.
The claims administrator must adopt the DWC regulations on the specific data and format required, and will need to submit within the determined timeframe. In addition, the DWC stated that over the course of their experience of collecting utilization review data, there has been a considerable amount of variation indicating the lack of industry standard for utilization review process and data collection. From this we can be certain that there will be more requirements and changes to come.
* What does the DWC define as a Utilization Review (or UR)? “4610. (a) For purposes of this section, “utilization review” means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians.” Based off the DWC’s definition of Utilization Review it seems safe to say that ALL approvals done at the URO or adjuster level are subject to the electronic reporting criteria of SB 1160.
Now the real question is… As an entity responsible for this operational mandate, what can you do to prepare?
Have an electronic system already in place to comply with the upcoming DWC regulation!
DataCare’s UR++ Platform was built with a workflow that automatically tracks all Request-for-Authorizations or RFA’s at the start of the UR process. UR++ was also designed to directly integrate both medical guidelines and custom client-specific rules, meaning that whatever new regulations and categories come about from DWC or other entities, they can be uploaded to the UR++ rules engine (i.e. adjuster can approve up to 12 physical therapy visits or up to $500 dollars of DME etc). In addition, the platform comes with a document management system, tracks jurisdictional turnaround times and the number of treatments/prescriptions that were approved, and can integrate with virtually any platform for direct data transfer. These features will allow users to extract all the necessary data from the system with minimal effort and forward the correspondence to all stakeholders. In addition, DataCare will also send all the pertinent information back to your claims system. As a result, this platform will eliminate the risk of facing consequences due to delayed submissions.
Why use DataCare?
We have established a reputation for innovative and proactive problem solving: we provide solutions before they are needed- not only as a response to new regulations or shifts. DataCare software is flexible enough to adapt to any requirements that the DWC decides.
Over the past decade, DataCare has established over 250 Electronic Data Interchanges or EDI’s with both major and smaller brand claims systems for UR, Managed Care, Self-Insured, and Insurance companies. This ensures a seamless transition from the start of a UR to the end stage of reporting data to the DWC. DataCare’s software runs on a private cloud network and is offered on a SaaS model. Visit datacare.com today and request a free demo to learn how the system can bring your company up to speed with SB1160.