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HOUSE OF REPRESENTATIVES - FLOOR VERSION
STATE OF OKLAHOMA
1st Session of the 58th Legislature (2021)
COMMITTEE SUBSTITUTE
FOR ENGROSSED
SENATE BILL NO. 724 By: Dahm of the Senate
and
Gann of the House
COMMITTEE SUBSTITUTE
An Act relating to the Physician Advisory Committee;
amending Section 50, Chapter 208, O.S.L. 2013, as
last amended by Section 1, Chapter 34, O.S.L. 2020
(85A O.S. Supp. 2020, Section 50), which relates to
medical examination and treatment; removing authority
to establish parameters for certain maintenance or
treatment; repealing Section 17, Chapter 208, O.S.L.
2013 (85A O.S. Supp. 2020, Section 17), which relates
to appointment and duties; repealing Section 60,
Chapter 208, O.S.L. 2013, as amended by Section 22,
Chapter 476, O.S.L. 2019 (85A O.S. Supp. 2020,
Section 60), which relates to adoption of alternative
method to evaluate permanent disability; and
providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY Section 50, Chapter 208, O.S.L.
2013, as last amended by Section 1, Chapter 34, O.S.L. 2020 (85A
O.S. Supp. 2020, Section 50), is amended to read as follows:
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Section 50. A. The employer shall promptly provide an injured
employee with medical, surgical, hospital, optometric, podiatric,
chiropractic and nursing services, along with any medicine,
crutches, ambulatory devices, artificial limbs, eyeglasses, contact
lenses, hearing aids , and other apparatus as may be reasonably
necessary in connection with the injury received by the employee.
The employer shall have the right to choose the treating physician
or chiropractor.
B. If the employer fails or neglects to provide medical
treatment within five (5) days after actual knowledge is received of
an injury, the injured employee may select a physician or
chiropractor to provide medical treatment at the expense of the
employer; provided, however, that the injured employee, or another
in the employee’s behalf, may obtain emergency treatment at the
expense of the employer where such emergency treatment is not
provided by the employer.
C. Diagnostic tests shall not be repeated sooner than six (6)
months from the date of the test unless agreed to by the parties or
ordered by the Commission for good ca use shown.
D. Unless recommended by the treating doctor or chiropractor at
the time claimant reaches maximum medical improvement or by an
independent medical examiner, continuing medical maintenance shall
not be awarded by the Commission. The employer or insurance carrier
shall not be responsible for continuing medical maintenance or pain
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management treatment that is outside the parameters established by
the Physician Advisory Committee or Official Disability Guidelines
(ODG). The employer or insurance c arrier shall not be responsible
for continuing medical maintenance or pain management treatment not
previously ordered by the Commission or approved in advance by the
employer or insurance carrier.
E. An employee claiming or entitled to benefits under the
Administrative Workers’ Compensation Act, shall, if ordered by the
Commission or requested by the employer or insurance carrier, submit
himself or herself for medical examination. If an employee refuses
to submit himself or herself to examination, his or her right to
prosecute any proceeding under the Administrative Workers’
Compensation Act shall be suspended, and no compensation shall be
payable for the period of such refusal.
F. For compensable injuries resulting in the use of a medical
device, ongoing service for the medical device shall be provided in
situations including, but not limited to, medical device battery
replacement, ongoing medication refills related to the medical
device, medical device repair, or medical device replacement.
G. The employer shall reimburse the employee for the actual
mileage in excess of twenty (20) miles round trip to and from the
employee’s home to the location of a medical service provider for
all reasonable and necessary treatment, for an evaluation of an
independent medical examiner and for any evaluation made at the
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request of the employer or insurance carrier. The rate of
reimbursement for such travel expense shall be the official
reimbursement rate as established by the State Travel Reimbursement
Act. In no event shall the reimbursement of travel for medical
treatment or evaluation exceed six hundred (600) miles round trip.
H. Fee Schedule.
1. The Commission shall conduct a review and update of the
Current Procedural Terminology (CPT) in the Fee Schedule every two
(2) years pursuant to the provisions of paragraph 14 of this
subsection. The Fee Schedule shall establish the maximum rates that
medical providers shall be reimbursed for medical care provided to
injured employees including, but not limited to, charge s by
physicians, chiropractors, dentists, counselors, hospitals,
ambulatory and outpatient facilities, clinical laboratory services,
diagnostic testing services, and ambulance services, and charges for
durable medical equipment, prosthetics, orthotics, and supplies.
The most current Fee Schedule established by the Administrator of
the Workers’ Compensation Court prior to February 1, 2014, shall
remain in effect, unless or until the Legislature approves the
Commission’s proposed Fee Schedule.
2. Reimbursement for medical care shall be prescribed and
limited by the Fee Schedule. The director of the Employees Group
Insurance Division of the Office of Management and Enterprise
Services shall provide the Commission such information as may be
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relevant for the development of the Fee Schedule. The Commission
shall develop the Fee Schedule in a manner in which quality of
medical care is assured and maintained for injured employees. The
Commission shall give due consideration to additional requirements
for physicians treating an injured worker under the Administrative
Workers’ Compensation Act , including, but not limited to,
communication with claims representatives, case managers, attorneys ,
and representatives of employers, and the additional time required
to complete forms for the Commission, insurance carriers, and
employers.
3. In making adjustments to the Fee Schedule, the Commission
shall use, as a benchmark, the reimbursement rate for each Current
Procedural Terminology (CPT) code provided for in the fee sc hedule
published by the Centers for Medicare and Medicaid Services of the
U.S. Department of Health and Human Services for use in Oklahoma
(Medicare Fee Schedule) on the effective date of this section,
workers’ compensation fee schedules employed by neighb oring states,
the latest edition of "Relative Values for Physicians" (RVP), usual,
customary and reasonable medical payments to workers’ compensation
health care providers in the same trade area for comparable
treatment of a person with similar injuries, a nd all other data the
Commission deems relevant. For services not valued by CMS, the
Commission shall establish values based on the usual, customary and
reasonable medical payments to health care providers in the same
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trade area for comparable treatment o f a person with similar
injuries.
a. No reimbursement shall be allowed for any magnetic
resonance imaging (MRI) unless the MRI is provided by
an entity that meets Medicare requirements for the
payment of MRI services or is accredited by the
American College of Radiology, the Intersocietal
Accreditation Commission or the Joint Commission on
Accreditation of Healthcare Organizations. For all
other radiology procedures, the reimbursement rate
shall be the lesser of the reimbursement rate allowed
by the 2010 Oklahoma Fee Schedule and two hundred
seven percent (207%) of the Medicare Fee Schedule.
b. For reimbursement of medical services for Evaluation
and Management of injured employees as defined in the
Fee Schedule adopted by the Commission, the
reimbursement rate shall not be less than one hundred
fifty percent (150%) of the Medicare Fee Schedule.
c. Any entity providing durable medical equipment,
prosthetics, orthotics or supplies shall be accredited
by a CMS-approved accreditation organization. If a
physician provides durable medical equipment,
prosthetics, orthotics, prescription drugs , or
supplies to a patient ancillary to the patient’s
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visit, reimbursement shall be no more than ten percent
(10%) above cost.
d. The Commission shall develop a reasonable sto p-loss
provision of the Fee Schedule to provide for adequate
reimbursement for treatment for major burns, severe
head and neurological injuries, multiple system
injuries, and other catastrophic injuries requiring
extended periods of intensive care. An emp loyer or
insurance carrier shall have the right to audit the
charges and question the reasonableness and necessity
of medical treatment contained in a bill for treatment
covered by the stop-loss provision.
4. The right to recover charges for every type of medical care
for injuries arising out of and in the course of covered employment
as defined in the Administrative Workers’ Compensation Act shall lie
solely with the Commission. When a medical care provider has
brought a claim to the Commission to obtain payment for services, a
party who prevails in full on the claim shall be entitled to
reasonable attorney fees.
5. Nothing in this section shall prevent an employer, insurance
carrier, group self-insurance association, or certified workplace
medical plan from contracting with a provider of medical care for a
reimbursement rate that is greater than or less than limits
established by the Fee Schedule.
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6. A treating physician may not charge more than Four Hundred
Dollars ($400.00) per hour for preparation fo r or testimony at a
deposition or appearance before the Commission in connection with a
claim covered by the Administrative Workers’ Compensation Act.
7. The Commission’s review of medical and treatment charges
pursuant to this section shall be conducted pursuant to the Fee
Schedule in existence at the time the medical care or treatment was
provided. The judgment approving the medical and treatment charges
pursuant to this section shall be enforceable by the Commission in
the same manner as provided in th e Administrative Workers’
Compensation Act for the enforcement of other compensation payments.
8. Charges for prescription drugs dispensed by a pharmacy shall
be limited to ninety percent (90%) of the average wholesale price of
the prescription, plus a di spensing fee of Five Dollars ($5.00) per
prescription. "Average wholesale price" means the amount determined
from the latest publication designated by the Commission.
Physicians shall prescribe and pharmacies shall dispense generic
equivalent drugs when available. If the National Drug Code, or
"NDC", for the drug product dispensed is for a repackaged drug, then
the maximum reimbursement shall be the lesser of the original
labeler’s NDC and the lowest -cost therapeutic equivalent drug
product. Compounded medications shall be billed by the compounding
pharmacy at the ingredient level, with each ingredient identified
using the applicable NDC of the drug product, and the corresponding
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quantity. Ingredients with no NDC area are not separately
reimbursable. Payment shall be based on a sum of the allowable fee
for each ingredient plus a dispensing fee of Five Dollars ($5.00)
per prescription.
9. When medical care includes prescription drugs dispensed by a
physician or other medical care provider and the NDC fo r the drug
product dispensed is for a repackaged drug, then the maximum
reimbursement shall be the lesser of the original labeler’s NDC and
the lowest-cost therapeutic equivalent drug product. Payment shall
be based upon a sum of the allowable fee for eac h ingredient plus a
dispensing fee of Five Dollars ($5.00) per prescription. Compounded
medications shall be billed by the compounding pharmacy.
10. Implantables are paid in addition to procedural
reimbursement paid for medical or surgical services. A
manufacturer’s invoice for the actual cost to a physician, hospital
or other entity of an implantable device shall be adjusted by the
physician, hospital or other entity to reflect, at the time
implanted, all applicable discounts, rebates, considerations an d
product replacement programs and shall be provided to the payer by
the physician or hospital as a condition of payment for the
implantable device. If the physician, or an entity in which the
physician has a financial interest other than an ownership int erest
of less than five percent (5%) in a publically publicly traded
company, provides implantable devices, this relationship shall be
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disclosed to patient, employer, insurance company, third -party
commission, certified workplace medical plan, case manager s, and
attorneys representing claimant and defendant. If the physician, or
an entity in which the physician has a financial interest other than
an ownership interest of less than five percent (5%) in a publicly
traded company, buys and resells implantable devices to a hospital
or another physician, the markup shall be limited to ten percent
(10%) above cost.
11. Payment for medical care as required by the Administrative
Workers’ Compensation Act shall be due within forty -five (45) days
of the receipt by the employer or insurance carrier of a complete
and accurate invoice, unless the employer or insurance carrier has a
good-faith reason to request additional information about such
invoice. Thereafter, the Commission may assess a penalty up to
twenty-five percent (25%) for any amount due under the Fee Schedule
that remains unpaid on the finding by the Commission that no good -
faith reason existed for the delay in payment. If the Commission
finds a pattern of an employer or insurance carrier willfully and
knowingly delaying payments for medical care, the Commission may
assess a civil penalty of not more than Five Thousand Dollars
($5,000.00) per occurrence.
12. If an employee fails to appear for a scheduled appointment
with a physician or chiropractor, the em ployer or insurance company
shall pay to the physician or chiropractor a reasonable charge, to
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be determined by the Commission, for the missed appointment. In the
absence of a good-faith reason for missing the appointment, the
Commission shall order the e mployee to reimburse the employer or
insurance company for the charge.
13. Physicians or chiropractors providing treatment under the
Administrative Workers’ Compensation Act shall disclose under
penalty of perjury to the Commission, on a form prescribed b y the
Commission, any ownership or interest in any health care facility,
business, or diagnostic center that is not the physician’s or
chiropractor’s primary place of business. The disclosure shall
include any employee leasing arrangement between the phys ician or
chiropractor and any health care facility that is not the
physician’s or chiropractor’s primary place of business. A
physician’s or chiropractor’s failure to disclose as required by
this section shall be grounds for the Commission to disqualify t he
physician or chiropractor from providing treatment under the
Administrative Workers’ Compensation Act.
14. a. Beginning on May 28, 2019, the Commission shall
conduct an evaluation of the Fee Schedule, which shall
include an update of the list of Curre nt Procedural
Terminology (CPT) codes, a line item adjustment or
renewal of all rates, and amendment as needed to the
rules applicable to the Fee Schedule.
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b. The Commission shall contract with an external
consultant with knowledge of workers’ compensation fee
schedules to review regional and nationwide
comparisons of Oklahoma’s Fee Schedule rates and date
and market for medical services. The consultant shall
receive written and oral comment from employers,
workers’ compensation medical service and insuran ce
providers, self-insureds, group self -insurance
associations of this state and the public. The
consultant shall submit a report of its findings and a
proposed amended Fee Schedule to the Commission.
c. The Commission shall adopt the proposed amended Fee
Schedule in whole or in part and make any additional
updates or adjustments. The Commission shall submit a
proposed updated and adjusted Fee Schedule to the
President Pro Tempore of the Senate, the Speaker of
the House of Representatives and the Governor . The
proposed Fee Schedule shall become effective on July 1
following the legislative session, if approved by
Joint Resolution of the Legislature during the session
in which a proposed Fee Schedule is submitted.
d. Beginning on May 28, 2019, an external evaluation
shall be conducted and a proposed amended Fee Schedule
shall be submitted to the Legislature for approval
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during the 2020 legislative session. Thereafter, an
external evaluation shall be conducted and a proposed
amended Fee Schedule shall be su bmitted to the
Legislature for approval every two (2) years.
I. Formulary. The Commission by rule shall adopt a closed
formulary. Rules adopted by the Commission shall allow an appeals
process for claims in which a treating doctor determines and
documents that a drug not included in the formulary is necessary to
treat an injured employee’s compensable injury. The Commission by
rule shall require the use of generic pharmaceutical medications and
clinically appropriate over -the-counter alternatives to pre scription
medications unless otherwise specified by the prescribing doctor, in
accordance with applicable state law.
SECTION 2. REPEALER Section 17, Chapter 208, O.S.L. 2013
(85A O.S. Supp. 2020, Section 17), is hereby repealed.
SECTION 3. REPEALER Section 60, Chapter 208, O.S.L.
2013, as amended by Section 22, Chapter 476, O.S.L. 2019 (85A O.S.
Supp. 2020, Section 60), is hereby repealed.
SECTION 4. This act shall become effective November 1, 2021.
COMMITTEE REPORT BY: COMMITTEE ON PUBLIC HEALTH, dated 04/08/2021 -
DO PASS, As Amended.