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PRINTER'S NO. 857
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
881
Session of
2023
INTRODUCED BY R. MACKENZIE, KAUFFMAN AND M. MACKENZIE,
APRIL 10, 2023
REFERRED TO COMMITTEE ON LABOR AND INDUSTRY, APRIL 10, 2023
AN ACT
Amending the act of June 2, 1915 (P.L.736, No.338), entitled "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 liability and
compensation, further providing for the treatment of work-
related injuries; and, in procedure, further providing for
peer review.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 306(f.1)(6)(ii) of the act of June 2,
1915 (P.L.736, No.338), known as the Workers' Compensation Act,
is amended and paragraph (6) is amended by adding a subparagraph
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,
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disputes as to reasonableness or necessity of treatment by a
health care provider shall be resolved in accordance with the
following provisions:
* * *
(ii) The department shall assign a request for utilization
review to a utilization review organization at random. The
utilization review organization shall issue a written report of
its findings and conclusions within the time frame required by
the nationally recognized accreditation standards adopted by the
department under subparagraph (v). In no case shall the report
of findings and conclusions be issued more than thirty (30) days
after the receipt of a request.
* * *
(v) The department shall approve only those utilization
review organizations that it determines have obtained
certification or accreditation by a nationally recognized
organization with certification or accreditation standards
appropriate for resolving utilization issues for workers'
compensation programs. The following shall apply:
(A) Within thirty (30) days of the effective date of this
subclause, the department shall transmit notice to the
Legislative Reference Bureau for publication in the next
available issue of the Pennsylvania Bulletin of the specific
nationally recognized certification or accreditation that will
be required in order to be approved as a utilization review
organization.
(B) Upon publication under subclause (A), an entity without
the appropriate certification or accreditation may not engage in
utilization review under this act, except that an entity
approved as a utilization review organization by the department
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prior to the effective date of this subclause may continue to
engage in utilization review for up to eighteen (18) calendar
months after the publication of notice under subclause (A). If
the department determines that an entity approved as a
utilization review organization by the department prior to the
effective date of this subclause is actively attempting to
achieve the selected certification or accreditation, the entity
shall not be required to apply for reauthorization during the
eighteen-month period. A utilization review organization shall
adhere to the review standards of the selected nationally
recognized certification or accreditation organization for all
utilization review where the date of the injury is at least
eighteen (18) calendar months after the publication of notice
under subclause (A).
(C) The department shall enter into an agreement with the
selected nationally recognized certification or accreditation
organization to provide for the certification or accreditation
process for utilization review organizations and employes of
utilization review organizations, including the costs of any
audits required for the certification or accreditation process.
The department shall make reasonable attempts to negotiate a
reduction of the cost of the certification or accreditation
process. An entity approved as a utilization review organization
by the department prior to the effective date of this subclause,
including a surviving association that results from the merger
of two or more utilization review organizations under 15 Pa.C.S.
Ch. 3 Subch. C (relating to merger), shall be eligible to
participate in the initial certification or accreditation
process at no cost to the entity. After January 1, 2026, an
entity approved as a utilization review organization shall be
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eligible to participate in the process to renew its
certification or accreditation at no cost to the entity. An
entity for which the department has incurred costs under this
subclause shall reimburse the department for its costs related
to the most recent certification or accreditation for the
entity, if the entity does not successfully obtain the initial
or renewal certification or accreditation. The actual amount of
the cost to the department for the certification or
accreditation process under this subclause, not to exceed one
million five hundred thousand dollars ($1,500,000) annually,
shall be transferred to the department from the Workers'
Compensation Administration Fund.
(D) The department shall conduct outreach to all entities
approved as utilization review organizations by the department
prior to the effective date of this subclause. The outreach
shall include providing each entity with notice of the
requirements of this clause, guidance on how this clause will be
enforced by the department and information on how the entity may
participate in the required certification or accreditation
process at no cost under subclause (C).
* * *
Section 2. Section 420 of the act is amended 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
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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 reasonableness or necessity
[or frequency] 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.
(b) The board or workers' compensation judge, as the case
may be, shall fix the compensation of such physicians, surgeons,
and experts, and other peer review organizations which, when so
fixed, shall be paid out of the Workmen's Compensation
Administration Fund.
(c) 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 3. Within eight months of the effective date of this
section, the Department of Labor and Industry shall propose
regulations to implement the amendment or addition of section
306(f.1)(6)(ii) and (v) of the act.
Section 4. This act shall take effect in 60 days.
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