Inside Workers’ Comp Blog

How COVID-19 is Impacting Prior Auth Rules in Comp

Posted by Dan Maldonado on April 6, 2020

States adapting new policies and strategies to overcome access-to-care challenges

The COVID-19 pandemic has dramatically changed the health and social landscape of our country, impacting injured workers and their treating providers from several vectors.

Of immediate and increasing concern is access to medically necessary care for injured workers. In jurisdictions that regulate mandatory prior authorization for some medical services provided to injured workers, many are wondering how prior authorization rules and procedures might need to adapt to pandemic and shelter-at-home orders.

We are observing many state departments issuing emergency rules to relax requirements and time frames for workers’ compensation claims handling. New York recently issued an emergency order, guiding stakeholders to conduct claim-handling activities remotely where possible, and relaxing time frames and penalties for independent medical examinations (IMEs), depositions, and other state-filing procedures. The Texas Department of Insurance has also issued several bulletins on emergency orders that relax or even suspend certain state filing requirements related to work comp claims handling.

So far, though, state departments are unanimously asking employers and insurers to maintain compliance with time frames for claims adjusting and other claims services, including prior authorization of medical services, where mandated.

What does this mean for insurance carriers and their utilization review partners? Resilient procedures and dedication to maintain business operations during this crisis.

Maintaining communication

With injured workers and administrative staff largely sheltering at home, the reliance on telephonic and electronic communications has never been greater. While many insurance carriers, provider offices, and UR organizations have capacity to continue administrative operations with remote-working staff, securing telephonic and electronic communication to the injured worker may present a challenge.

Nonetheless, industry leaders are advocating that electronic communication be utilized whenever possible to accommodate our current crisis. The Tennessee Bureau of Workers’ Compensation has issued a comprehensive announcement that all meetings and communications should be done telephonically or electronically, where possible. New York is asking parties to conduct all hearings virtually, and Texas has issued guidance on securing electronic signature in lieu of in-person signatures on legal documents. Other state departments have issued similar notices.

State departments have broadly been pushing  telemedicine to accommodate office visits and ongoing treatment in communities where such services cannot be provided in-person at the moment. Claims professionals and their utilization review partners should be prepared to process requests for authorization based on virtual office visits, and the delivery of medical services via telemedicine. This even extends to services such as physical therapy, as we’ve seen the Washington State Department of Labor and Industries publish an emergency policy to guide and guarantee payment for therapy provided via telemedicine. New York published similar guidance to its constituents.

Increasing flexibility in regulations

State departments have also encouraged insurers to extend dates and duration of medical service authorizations. For instance, in Louisiana, emergency rules have been adopted that increase authorization timelines from 30 to 90 days, and allow for early refills of most prescription medications. The Florida Office of Insurance Regulation has issued similar guidance to remove restrictions on early refills for most medications, and support pharmacies on dispensing a 30-day supply of most medications even without prior authorization. The Texas Division of Workers’ Compensation has instructed carriers to authorize payment to pharmacies for up to a 90-day supply for medications prescribed by treating providers, subject to prescription limits, regardless of previous prescription fill dates.

While the novel coronavirus pandemic continues to reshape our lives and our livelihoods, what is clear and worth emphasizing is that we, as an industry, are united in ensuring claims professionals and injured workers continue to have access to essential services and medical care.

Dan Maldonado, DC, is clinical director for utilization review and physician advisory services at Genex Services.


Need to reduce your total cost of risk?

To help lower your total cost of risk and return injured workers to work as quickly as possible, we offer a FREE consultation with a workers’ comp expert. Together, we will begin to build a workers' comp program to meet your company’s unique needs.