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PRINTER'S NO. 2681
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1800
Session of
2015
INTRODUCED BY MACKENZIE, COHEN, GROVE, A. HARRIS, HEFFLEY,
McNEILL AND MILLARD, DECEMBER 18, 2015
REFERRED TO COMMITTEE ON LABOR AND INDUSTRY, DECEMBER 18, 2015
AN ACT
Amending the act of June 2, 1915 (P.L.736, No.338), entitled, as
reenacted and amended, "An act defining the liability of an
employer to pay damages for injuries received by an employe
in the course of employment; establishing an elective
schedule of compensation; providing procedure for the
determination of liability and compensation thereunder; and
prescribing penalties," in interpretation and definitions,
further providing for definitions; in liability and
compensation, further providing for schedule of compensation;
and, in procedure, further providing for investigations and
peer review.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The definition of "utilization review
organizations" in section 109 of the act of June 2, 1915
(P.L.736, No.338), known as the Workers' Compensation Act,
reenacted and amended June 21, 1939 (P.L.520, No.281) and added
July 2, 1993 (P.L.190, No.44), is amended to read:
Section 109. In addition to the definitions set forth in
this article, the following words and phrases when used in this
act shall have the meanings given to them in this section unless
the context clearly indicates otherwise:
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* * *
"Utilization review organizations" shall be those
organizations consisting of an impartial physician, surgeon or
other health care provider or a panel of such professionals and
providers as [authorized] approved by the [Secretary] Department
of Labor and Industry and published as a list in the form of a
notice in the Pennsylvania Bulletin for the purpose of reviewing
the reasonableness and necessity of treatment by a health care
provider pursuant to section 306(f.1)(6).
Section 2. Section 306(f.1)(6) of the act, amended June 24,
1996 (P.L.350, No.57), is amended to read:
Section 306. The following schedule of compensation is
hereby established:
* * *
(f.1) * * *
(6) [Except in those cases in which a workers' compensation
judge asks for an opinion from peer review under section 420,
disputes] Disputes as to reasonableness or necessity of
treatment by a health care provider shall be resolved in
accordance with the following provisions:
[(i) The reasonableness or necessity of all treatment
provided by a health care provider under this act may be subject
to prospective, concurrent or retrospective utilization review
at the request of an employe, employer or insurer. The
department shall authorize utilization review organizations to
perform utilization review under this act. Utilization review of
all treatment rendered by a health care provider shall be
performed by a provider licensed in the same profession and
having the same or similar specialty as that of the provider of
the treatment under review. Organizations not authorized by the
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department may not engage in such utilization review.]
(i) For purposes of this section, reasonable and necessary
treatments, services, products or accommodations shall be those
treatments, services, products or accommodations that are
consistent with or recommended by evidence-based medical
treatment guidelines selected and referenced by the department
by publication in the Pennsylvania Bulletin. In selecting the
guidelines, the department shall choose from nationally
recognized treatment guidelines appropriate for resolving issues
relating to treatment for work-related injuries. The department
shall allow modifications from the guidelines based on a panel
of providers as provided in subparagraph (ii), following public
notice and the opportunity for comment.
(ii) The following shall apply:
(A) The secretary shall appoint a panel of medical providers
for the purpose of proposing modifications to the guidelines
referenced in subparagraph (i), including one medical provider
from each of the following licenses and specialties:
(I) Occupational medicine.
(II) Orthopedic medicine.
(III) Neurosurgical medicine.
(IV) Pain management.
(V) Physical therapy.
(VI) Chiropractic medicine.
(B) An item listed under clause (A) may include an
osteopathic equivalent.
(C) The providers under this subparagraph shall serve
without remuneration and shall be appointed for a six-year term.
The panel shall meet to review the guidelines, consider public
comments and recommend modifications no less than once each
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calendar year.
(iii) An injured worker may challenge an employer's
determination of reasonableness or necessity by filing a request
for utilization review with a utilization review organization
approved by the department. The purpose of a utilization review
conducted pursuant to this section shall be to determine if the
treatment is consistent with or recommended by the treatment
guidelines referenced in subparagraph (i).
(iv) The department shall approve only those utilization
review organizations that it determines have satisfied the
criteria of a nationally recognized accrediting organization
referenced by the department by publication in the Pennsylvania
Bulletin, at a rate established by the department.
[(ii)] (v) The utilization review organization shall issue a
written report of its findings and conclusions within thirty
(30) days of a request.
[(iii)] (vi) The employer or the insurer shall pay the cost
of the utilization review.
[(iv)] (vii) If the provider, employer, employe or insurer
disagrees with the finding of the utilization review
organization, a petition for review by the department must be
filed within thirty (30) days after receipt of the report. The
department shall assign the petition to a workers' compensation
judge for a hearing or for an informal conference under section
402.1. The utilization review report shall be part of the record
before the workers' compensation judge. The workers'
compensation judge shall consider the utilization review report
as evidence but shall not be bound by the report.
* * *
Section 3. Section 420(a) of the act, amended June 24, 1996
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(P.L.350, No.57), is amended and the section is amended by
adding a subsection to read:
Section 420. (a) The board, the department or a workers'
compensation judge, if it or he deem it necessary, may, of its
or his own motion, either before, during, or after any hearing,
make or cause to be made an investigation of the facts set forth
in the petition or answer or facts pertinent in any injury under
this act. The board, department or workers' compensation judge
may appoint one or more impartial physicians or surgeons to
examine the injuries of the plaintiff and report thereon, or may
employ the services of such other experts as shall appear
necessary to ascertain the facts. The workers' compensation
judge when necessary or appropriate or upon request of a party
in order to rule on requests for review filed under section
306(f.1), or under other provisions of this act, may ask for an
opinion from peer review about the necessity or [frequency]
appropriateness of treatment under section 306(f.1). The peer
review report or the peer report of any physician, surgeon, or
expert appointed by the department or by a workers' compensation
judge, including the report of a peer review organization, shall
be filed with the board or workers' compensation judge, as the
case may be, and shall be a part of the record and open to
inspection as such. The workers' compensation judge shall
consider the report as evidence but shall not be bound by such
report.
(a.1) Peer review performed under this section and peer
review organizations used under this section shall comply with
the requirements established under section 306(f.1)(6).
* * *
Section 4. This act shall take effect in 60 days.
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