OVERVIEW OF WORKERS’
COMPENSATION FOR WEST
VIRGINIA PROVIDERS
March 2012
Leah Klinke
West Virginia United Insurance Services
Health Partners Network
Overview of WV Workers’ Comp
• History of Workers’ Comp in West Virginia
• Jurisdiction – Which State’s rules will apply?
• West Virginia Rules & Reimbursement
• Other State Rules & Reimbursement
• Important Documents & Reference Tools
HISTORY OF WORKERS’
COMP IN WEST VIRGINIA
History of Workers’ Comp in WV
• Prior to January 1, 2006, workers’ compensation was
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managed exclusively by the State of West Virginia
Brickstreet was established by the State of West Virginia
on January 1, 2006 as an alternative plan to the state
insurance fund.
As the sole private entity in the state, Brickstreet enjoyed
a monopoly in the West Virginia market.
On November 1, 2007, Brickstreet established a PPO
product “StreetSelect” to prepare for coming competition.
On July 1, 2008, the West Virginia Workers’
Compensation market opened to private insurers.
Brickstreet became just one of many private insurers in
the market.
History of Workers’ Comp in WV
• West Virginia’s workers’ compensation system
transitioned from a simple single payer system to a
competitive multi-payer system virtually overnight.
Why Change?
• Brickstreet was formed to replace a state-run system that
was expensive for employers, but provided generous
benefits for insured employees.
• The market was then opened up to competition between
many insurers.
• The goal for the system was to introduce competition and
lower premiums for employers in the state.
Changes for Providers
• In the single insurer system, providers knew who they
were dealing with and what they would expect to be paid
when an injured worker was treated in their facility.
• Under the new system, providers have to do a lot more
work to find out who they are dealing with and whether
they are in-network for a particular employee/patient.
• Reimbursement is challenging for many physicians and
hospitals as there is no longer a single fee schedule to
apply to all provider bills.
JURISDICTION – WHICH
STATE’S RULES WILL
APPLY?
Jurisdiction - Which State’s rules will
apply?
• Jurisdiction [joor-is-dik-shuhn] noun
• the right, power, or authority to administer justice by hearing and
determining controversies.
• power; authority; control.
• The state with jurisdiction is the state that will determine
what rules will apply to a particular claim. West Virginia
rules do not automatically apply just because a patient
received medical care in West Virginia.
• The following questions will help you to determine which
rules will apply to a particular bill.
Jurisdiction - Which State’s rules will
apply?
• Question #1: Where does the employee primarily work?
• In most of West Virigina’s surrounding states, the state in which the
employee primarily works is considered the patient’s home state.
• If the employee primarily works in more than one state, that
employer may be required to purchase workers’ compensation
insurance in both states. If so, jurisdiction will be determined by
question #2.
Jurisdiction - Which State’s rules will
apply?
• Question #2: Where was the employee injured?
• If an employer carries work comp in WV and another state the state
in which the employee was in at time of injury has jurisdiction over
the claim
Jurisdiction - Which State’s rules will
apply?
• Where can you find the information to answer the
Jurisdiction question?
• The “123 Form” is the form that should be filled out by each injured
employee at the time of the injury to initiate a claim. This form has
the patient list the location of their employer as well as the location
where the injury occurred. If this form is available, it is a good
source of information.
Jurisdiction - Which State’s rules will
apply?
• Example #1
• A patient is an employee of Consolidated Coal. The patient works
in more than one location: One in PA and one in WV. The patient
was working at a West Virginia mine when injured.
• In this example, the “Home State” could be West Virginia or
Pennsylvania. Because the employee was injured in West Virginia,
West Virginia's workers’ compensation rules should apply to this
patient.
Jurisdiction - Which State’s rules will
apply?
• Example #2
• A patient is an employee of First Energy. The patient lives in PA,
but primarily works in Maryland reading meters. The patient was
injured in Maryland, then seen at a West Virginia hospital.
• In this example, the “Home State” would be Maryland because that
is the state where the employee primarily works.
WEST VIRGINIA RULES &
REIMBURSEMENT
West Virginia Rules and Regulations
• State maximum medical reimbursement is set at 135% of
Medicare for in and outpatient hospital and physician
medical care.
• Specific documents outlining the fee schedule can be
found at:
http://www.wvinsurance.gov/WorkersCompensation/WCManagedHe
althCarePlansFeesschedule/Schedule.aspx
Managed Health Care Plans
(MHCPs)
• West Virginia allows an “approved Managed Health Care
Plan” (MHCP) to negotiate for contract rates outside of the
state fee schedule since WC insurance is now privatized
• Approved Managed Health Care Plans (MHCPs) are
exempt from the state maximum fee schedule
• Negotiated rates can be above the rates outlined in the
state fee schedule
• Because MHCPs are exempt from the state maximum,
reimbursement from a non-contracted MHCP should be
expected at 100% of billed charges.
Approved MHCPs
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CompNET
4COMP Network
CompKey, Forte, Inc
CorVel West Virginia
KHA Solutions Group
Travelers & Constitution
Coventry Workers' Comp
Services
• GENEX Se
• Liberty Mutual Services
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MedInsights, Inc.
Rising-Rockport
Bunch & Associates, LLC
Brickstreet Mutual
Insurance Company/
StreetSelect
• Procura Management, Inc.
HMOs
• The Health Plan of the
Upper Ohio Valley, Inc.
Non Contracted - MHCPs
• Providers should attempt to negotiate single case
agreements with non-contracted MHCPs at rates above
what the contracted MHCPs pay.
• When no agreement is made in advance, payers may
attempt to pay a rate below the provider’s billed charges.
In these cases, an appeal needs to be made to the payer
for additional payment.
• Requiring non-contracted payer to agree to a rate above
the state fee schedule in advance of services being
rendered opens up the opportunity for a contract
negotiation to get the payer in-network for future patients.
Not Part of an MHCP
• If a patient is covered under a plan that is not part of an
approved MHCP, the reimbursement is expected to be at
the state maximum of 135% of Medicare
• Reimbursement is NOT limited to billed charges in WV
• The Workers’ Compensation code states that these
payers can contract for rates other than the state
maximum
Not Part of an MHCP
• Example:
• A patient who is a Wal-Mart employee who has been injured on
the job attempts to schedule elective surgery at your facility.
• The employer group/carrier is identified as a group that is not part
of an MHCP in advance of scheduling. Negotiations should be
initiated.
• Employers and/or carriers who are not part of MHCPs are finding
it difficult to coordinate care for injured employees as many
providers will not take workers’ compensation cases. This creates
an incentive for the employer and/or carrier to establish an
agreement with a provider to provide the care their employee
needs.
Is this claim part of an MHCP?
• Good Question! Here are some tips to help you out:
• Develop a list of common employers and their insurance carrier.
• Link those carriers to the approved MHCP (if any)
• Distribute this list to patient access representatives and
schedulers in the common Work related injury departments (e.g.
orthopedics, neurology, emergency department). This will assist
in proper insurance selection up front. It will also let the
schedulers know whether a special agreement needs to be
negotiated with an out of network payer/MHCP.
• Facilitate completion of the 1-2-3 form if the patient arrives in your
ED. The form tells the employer name and the location where the
injury occurred. A template of the 1-2-3 form can be found on the
insurance commission website.
• The patient will also receive an “insurance card” once the claim is
established showing the MHCP the patient is a part of.
Is this claim part of an MHCP?
• West Virginia law requires an insurance company to
provide injured employees with an “insurance card”
showing which MHCP the patient is a part of. This comes
attached to a letter and is mailed to the patient once the
claim is established.
OTHER STATE RULES &
REIMBURSEMENT
Other State Rules & Reimbursement
• For the most part, each state sets its own rates for
patients who travel outside the home state for treatment
or specifies that the out-of-state provider’s own states
rates will apply.
• Many providers have seen an increase in out-of-state
claims due to energy production in the state which brings
employees to work in West Virginia on a temporary basis.
Other State Rules & Reimbursement
• Pennsylvania –
• Inpatient hospital claims are paid at a DRG calculation
using version 12 DRGs based on the Harrisburg, PA
locality.
• Outpatient hospital is paid based on Medicare HCPCS
rates out of Harrisburg, PA as of January 1, 1995 or
when a new code was first introduced
• Physician reimbursement is based on Medicare Part B
reimbursement based on the Harrisburg, PA locality
• Reimbursement is limited to the billed amount for all
schedules listed above.
Other State Rules & Reimbursement
• Ohio –
• Inpatient hospital claims are paid at 61% of billed
charges.
• Outpatient hospital is paid at 61% of billed charges.
• Physician reimbursement is based on Ohio rates.
Other State Rules & Reimbursement
• Maryland –
• No out of state treatment fee schedule is specified.
• Will access PPO discounts where they are entitled
(have seen One Net, First Health).
• Otherwise, will pay based on WV State Fee schedule
IMPORTANT DOCUMENTS &
REFERENCE TOOLS
Important Reference Tools
• West Virginia law requires an insurance company to
provide injured employees with an “insurance card”
showing which MHCP the patient is a part of.
• 123 Form contains valuable information related to the
jurisdiction question such as the employer’s address and
location where injury occurred.
Important Reference Tools
• State of West Virginia Workers’ Comp Insurance
Validation System - https://www.ewccv.com/cvs/
• State of West Virginia Workers’ Comp Website:
http://www.wvinsurance.gov/WorkersCompensation/
Important Reference Tools
• State of West Virginia Workers’ Comp Insurance
Validation System - https://www.ewccv.com/cvs/
Enter employer’s
name and service
date
Important Reference Tools
• State of West Virginia Workers’ Comp Insurance
Validation System - https://www.ewccv.com/cvs/
Returns the name of
the insurance
company for that
employer
Questions?