As Introduced

129th General Assembly
Regular Session
2011-2012
H. B. No. 517


Representatives Sears, Newbold 

Cosponsors: Representatives Henne, Hackett, Buchy, Amstutz, Beck, Grossman, Adams, J., Rosenberger, Wachtmann, Sprague, McGregor 

A BILL
To amend sections 4121.44, 4121.441, 4121.63, 1
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93 2
of the Revised Code to allow the Administrator of 3
Workers' Compensation to pay for specified medical 4
benefits during an earlier time frame, to require 5
a workers' compensation claimant that refuses or 6
unreasonably delays treatment without good cause 7
to forfeit compensation and benefits during the 8
time period of refusal or delay, to make changes 9
to the health partnership program, and to make 10
other changes to the Workers' Compensation Law.11


BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

       Section 1. That sections 4121.44, 4121.441, 4121.63, 12
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93 of the Revised 13
Code be amended to read as follows:14

       Sec. 4121.44.  (A) The administrator of workers' compensation 15
shall oversee the implementation of the Ohio workers' compensation 16
qualified health plan system as established under section 4121.442 17
of the Revised Code.18

       (B) The administrator shall direct the implementation of the 19
health partnership program administered by the bureau as set forth 20
in section 4121.441 of the Revised Code. To implement the health 21
partnership program, the bureau:22

       (1) Shall certify one or more external vendors, which shall 23
be known as "managed care organizations," to provide medical 24
management and cost containment services in the health partnership 25
program for a period of two years beginning on the date of 26
certification, consistent with the standards established under 27
this section;28

       (2) May recertify external vendors for additional periods of 29
two years; and30

       (3) May integrate the certified vendors with bureau staff and 31
existing bureau services for purposes of operation and training to 32
allow the bureau to assume operation of the health partnership 33
program at the conclusion of the certification periods set forth 34
in division (B)(1) or (2) of this section.35

       (C) Any vendor selected shall demonstrate all of the 36
following:37

       (1) Arrangements and reimbursement agreements with a provider 38
panel including a substantial number of the medical, professional,39
and pharmacy providers currently being utilized by claimants40
participating in the health partnership program, selected on the 41
basis of access, quality, and cost.42

       (2) Ability to accept a common format of medical bill data in 43
an electronic fashion from any provider who wishes to submit 44
medical bill data in that form.45

       (3) A computer system able to handle the volume of medical 46
bills and willingness to customize that system to the bureau's 47
needs and to be operated by the vendor's staff, bureau staff, or 48
some combination of both staffs.49

       (4) A prescription drug system where pharmacies on a 50
statewide basis have access to the eligibility and pricing, at a 51
discounted rate, of all prescription drugs.52

       (5) A tracking system to record all telephone calls from 53
claimants and providers regarding the status of submitted medical 54
bills so as to be able to track each inquiry.55

       (6) Data processing capacity to absorb all of the bureau's 56
medical bill processing or at least that part of the processing 57
which the bureau arranges to delegate.58

       (7) Capacity to store, retrieve, array, simulate, and model 59
in a relational mode all of the detailed medical bill data so that 60
analysis can be performed in a variety of ways and so that the 61
bureau and its governing authority can make informed decisions.62

       (8) Wide variety of software programs which translate medical 63
terminology into standard codes, and which reveal if a provider is 64
manipulating the procedures codes, commonly called "unbundling."65

       (9) Necessary professional staff to conduct, at a minimum, 66
authorizations for treatment, medical necessity, utilization 67
review, concurrent review, post-utilization review, and have the 68
attendant computer system which supports such activity and 69
measures the outcomes and the savings.70

       (10) Management experience and flexibility to be able to 71
react quickly to the needs of the bureau in the case of required 72
change in federal or state requirements.73

       (D) For purposes of division (C)(1) of this section, any 74
provider panel used by a vendor shall provide reasonable access to 75
providers, deliver cost-effective treatment, and achieve quality 76
benchmarks established by the administrator.77

       (E)(1) Information contained in a vendor's application for 78
certification in the health partnership program, and other 79
information furnished to the bureau by a vendor for purposes of 80
obtaining certification or to comply with performance and 81
financial auditing requirements established by the administrator, 82
is for the exclusive use and information of the bureau in the 83
discharge of its official duties, and shall not be open to the 84
public or be used in any court in any proceeding pending therein, 85
unless the bureau is a party to the action or proceeding, but the 86
information may be tabulated and published by the bureau in 87
statistical form for the use and information of other state 88
departments and the public. No employee of the bureau, except as 89
otherwise authorized by the administrator, shall divulge any 90
information secured by the employee while in the employ of the 91
bureau in respect to a vendor's application for certification or 92
in respect to the business or other trade processes of any vendor 93
to any person other than the administrator or to the employee's 94
superior.95

       (2) Notwithstanding the restrictions imposed by division 96
(D)(E)(1) of this section, the governor, members of select or 97
standing committees of the senate or house of representatives, the 98
auditor of state, the attorney general, or their designees, 99
pursuant to the authority granted in this chapter and Chapter 100
4123. of the Revised Code, may examine any vendor application or 101
other information furnished to the bureau by the vendor. None of 102
those individuals shall divulge any information secured in the 103
exercise of that authority in respect to a vendor's application 104
for certification or in respect to the business or other trade 105
processes of any vendor to any person.106

       (E)(F) On and after January 1, 2001, a vendor shall not be 107
any insurance company holding a certificate of authority issued 108
pursuant to Title XXXIX of the Revised Code or any health insuring 109
corporation holding a certificate of authority under Chapter 1751. 110
of the Revised Code.111

       (F)(G) The administrator may limit freedom of choice of 112
health care provider or supplier by requiring, beginning with the 113
period set forth in division (B)(1) or (2) of this sectionthe 114
forty-sixth day after the date of the injury or the forty-sixth 115
day after the beginning date for treatment for the occupational 116
disease, that claimants shall pay an appropriate out-of-plan 117
copayment for selecting a medical provider not within the provider 118
panel of a health partnership program vendor as provided for in 119
this section.120

       (G)(H) The administrator, six months prior to the expiration 121
of the bureau's certification or recertification of the vendor or 122
vendors as set forth in division (B)(1) or (2) of this section, 123
may certify and provide evidence to the governor, the speaker of 124
the house of representatives, and the president of the senate that 125
the existing bureau staff is able to match or exceed the 126
performance and outcomes of the external vendor or vendors and 127
that the bureau should be permitted to internally administer the 128
health partnership program upon the expiration of the 129
certification or recertification as set forth in division (B)(1) 130
or (2) of this section.131

       (H)(I) The administrator shall establish and operate a bureau 132
of workers' compensation health care data program. The 133
administrator shall develop reporting requirements from all 134
employees, employers and medical providers, medical vendors, and 135
plans that participate in the workers' compensation system. The 136
administrator shall do all of the following:137

       (1) Utilize the collected data to measure and perform 138
comparison analyses of costs, quality, appropriateness of medical 139
care, and effectiveness of medical care delivered by all 140
components of the workers' compensation system.;141

       (2) Compile data to support activities of the selected vendor 142
or vendors andannually to measure the outcomes and savings of 143
managed care organizations and providers in the health partnership 144
program.;145

       (3) Publish and reportReport the compiled data on the 146
measures of outcomes and savings of the health partnership program 147
and submit the report to the president of the senate, the speaker 148
of the house of representatives, and the governor with the annual 149
report prepared under division (F)(3) of section 4121.12 of the 150
Revised Code. The administrator shall protect;151

       (4) Make the data compiled pursuant to division (I)(2) of 152
this section available to employers and the public;153

        (5) Protect the confidentiality of all proprietary pricing 154
data.155

       (I)(J) Any rehabilitation facility the bureau operates is 156
eligible for inclusion in the Ohio workers' compensation qualified 157
health plan system or the health partnership program under the 158
same terms as other providers within health care plans or the 159
program.160

       (J) In(K) Notwithstanding division (G) of this section, in161
areas outside the state or within the state where no qualified 162
health plan or an inadequate number of providers within the health 163
partnership program exist, the administrator shall permit 164
employees to use a provider not within the provider panel of a 165
qualified health plan or health partnership program vendor, 166
including, if necessary, a nonplan or nonprogram health care 167
provider and shall pay the provider for the services or supplies 168
provided to or on behalf of an employee for an injury or 169
occupational disease that is compensable under this chapter or 170
Chapter 4123., 4127., or 4131. of the Revised Code on a fee 171
schedule the administrator adopts.172

       (K)(L) No health care provider, whether certified or not, 173
shall charge, assess, or otherwise attempt to collect from an 174
employee, employer, a managed care organization, or the bureau any 175
amount for covered services or supplies that is in excess of the 176
allowed amount paid by a managed care organization, the bureau, or 177
a qualified health plan.178

       (L)(M) The administrator shall permit any employer or group 179
of employers who agree to abide by the rules adopted under this 180
section and sections 4121.441 and 4121.442 of the Revised Code to 181
provide services or supplies to or on behalf of an employee for an 182
injury or occupational disease that is compensable under this 183
chapter or Chapter 4123., 4127., or 4131. of the Revised Code 184
through qualified health plans of the Ohio workers' compensation 185
qualified health plan system pursuant to section 4121.442 of the 186
Revised Code or through the health partnership program pursuant to 187
section 4121.441 of the Revised Code. No amount paid under the 188
qualified health plan system pursuant to section 4121.442 of the 189
Revised Code by an employer who is a state fund employer shall be 190
charged to the employer's experience or otherwise be used in 191
merit-rating or determining the risk of that employer for the 192
purpose of the payment of premiums under this chapter, and if the 193
employer is a self-insuring employer, the employer shall not 194
include that amount in the paid compensation the employer reports 195
under section 4123.35 of the Revised Code.196

       Sec. 4121.441.  (A) The administrator of workers' 197
compensation, with the advice and consent of the bureau of 198
workers' compensation board of directors, shall adopt rules under 199
Chapter 119. of the Revised Code for the health care partnership 200
program administered by the bureau of workers' compensation to 201
provide medical, surgical, nursing, drug, hospital, and 202
rehabilitation services and supplies to an employee for an injury 203
or occupational disease that is compensable under this chapter or 204
Chapter 4123., 4127., or 4131. of the Revised Code.205

       The rules shall include, but are not limited to, the 206
following:207

       (1) Procedures for the resolution of medical disputes between 208
an employer and an employee, an employee and a provider, or an 209
employer and a provider, prior to an appeal under section 4123.511 210
of the Revised Code. Rules the administrator adopts pursuant to 211
division (A)(1) of this section may specify that the resolution 212
procedures shall not be used to resolve disputes concerning 213
medical services rendered that have been approved through standard 214
treatment guidelines, pathways, or presumptive authorization 215
guidelines.216

       (2) Prohibitions against discrimination against any category 217
of health care providers;218

       (3) Procedures for reporting injuries to employers and the 219
bureau by providers;220

       (4) Appropriate administrative and financial incentives to 221
reduce service cost and insure proper system utilization without 222
sacrificing the quality of service, including bonus payments to 223
providers who substantially exceed quality benchmarks established 224
by the administrator;225

       (5) Adequate methods of peer review, utilization review, 226
quality assurance, and dispute resolution to prevent, and provide 227
sanctions for, inappropriate, excessive or not medically necessary 228
treatment;229

       (6) A timely and accurate method of collection of necessary 230
information regarding medical and health care service and supply 231
costs, quality, and utilization to enable the administrator to 232
determine the effectiveness of the program;233

       (7) Provisions for necessary emergency medical treatment for 234
an injury or occupational disease provided by a health care 235
provider who is not part of the program;236

       (8) Discounted pricing for all in-patient and out-patient 237
medical services, all professional services, and all 238
pharmaceutical services;239

       (9) Provisions for provider referrals, pre-admission and 240
post-admission approvals, second surgical opinions, and other cost 241
management techniques;242

       (10) Antifraud mechanisms;243

       (11) Standards and criteria for the bureau to utilize in 244
certifying or recertifying a health care provider or a vendor for 245
participation in the health partnership program;246

       (12) Standards and criteria for the bureau to utilize in 247
penalizing or decertifying a health care provider or a vendor from 248
participation in the health partnership program.249

       (B) The administrator shall implement the health partnership 250
program according to the rules the administrator adopts under this 251
section for the provision and payment of medical, surgical, 252
nursing, drug, hospital, and rehabilitation services and supplies 253
to an employee for an injury or occupational disease that is 254
compensable under this chapter or Chapter 4123., 4127., or 4131. 255
of the Revised Code.256

       Sec. 4121.63.  Claimants who the administrator of workers' 257
compensation determines could probably be rehabilitated to achieve 258
the goals established by section 4121.61 of the Revised Code and 259
who agree to undergo rehabilitation shall be paid living 260
maintenance payments for a period or periods which do not exceed 261
six months in the aggregate, unless review by the administrator or 262
the administrator's designee reveals that the claimant will be 263
benefited by an extension of such payments.264

       Living maintenance payments shall be paid in weekly amounts, 265
not to exceed the amount the claimant would receive if the 266
claimant were being compensated for temporary total disability, 267
but not less than fifty per cent of the current state average 268
weekly wage. Living maintenance payments shall commence at the 269
time the claimant begins to participate in an approved 270
rehabilitation program.271

       A claimant receiving living maintenance payments shall be 272
deemed to be temporarily totally disabled and shall receive no 273
payment of any type of compensation except as provided by division 274
(B) of section 4123.57 of the Revised Code for the periods during 275
which the claimant is receiving living maintenance payments.276

       If, without good cause, a claimant refuses to undertake or 277
unreasonably delays undertaking rehabilitation services, 278
counseling, or training in accordance with an approved 279
rehabilitation plan, the claimant forfeits the claimant's right to 280
have the claimant's claim for compensation or benefits considered, 281
if the claim is pending before the administrator or the industrial 282
commission, or to receive living maintenance payments or any other 283
payment for compensation or benefits pertaining to the period of 284
refusal. The period of refusal or obstruction shall not toll any 285
time frame for the exercise of continuing jurisdiction by the 286
administrator or commission under section 4123.52 of the Revised 287
Code.288

       Sec. 4123.511.  (A) Within seven days after receipt of any 289
claim under this chapter, the bureau of workers' compensation 290
shall notify the claimant and the employer of the claimant of the 291
receipt of the claim and of the facts alleged therein. If the 292
bureau receives from a person other than the claimant written or 293
facsimile information or information communicated verbally over 294
the telephone indicating that an injury or occupational disease 295
has occurred or been contracted which may be compensable under 296
this chapter, the bureau shall notify the employee and the 297
employer of the information. If the information is provided 298
verbally over the telephone, the person providing the information 299
shall provide written verification of the information to the 300
bureau according to division (E) of section 4123.84 of the Revised 301
Code. The receipt of the information in writing or facsimile, or 302
if initially by telephone, the subsequent written verification, 303
and the notice by the bureau shall be considered an application 304
for compensation under section 4123.84 or 4123.85 of the Revised 305
Code, provided that the conditions of division (E) of section 306
4123.84 of the Revised Code apply to information provided verbally 307
over the telephone. Upon receipt of a claim, the bureau shall 308
advise the claimant of the claim number assigned and the 309
claimant's right to representation in the processing of a claim or 310
to elect no representation. If the bureau determines that a claim 311
is determined to be a compensable lost-time claim, the bureau 312
shall notify the claimant and the employer of the availability of 313
rehabilitation services. No bureau or industrial commission 314
employee shall directly or indirectly convey any information in 315
derogation of this right. This section shall in no way abrogate 316
the bureau's responsibility to aid and assist a claimant in the 317
filing of a claim and to advise the claimant of the claimant's 318
rights under the law.319

       The administrator of workers' compensation shall assign all 320
claims and investigations to the bureau service office from which 321
investigation and determination may be made most expeditiously.322

       The bureau shall investigate the facts concerning an injury 323
or occupational disease and ascertain such facts in whatever 324
manner is most appropriate and may obtain statements of the 325
employee, employer, attending physician, and witnesses in whatever 326
manner is most appropriate.327

       The administrator, with the advice and consent of the bureau 328
of workers' compensation board of directors, may adopt rules that 329
identify specified medical conditions that have a historical 330
record of being allowed whenever included in a claim. The 331
administrator may grant immediate allowance of any medical 332
condition identified in those rules upon the filing of a claim 333
involving that medical condition and may make immediate payment of 334
medical bills for any medical condition identified in those rules 335
that is included in a claim. If an employer contests the allowance 336
of a claim involving any medical condition identified in those 337
rules, and the claim is disallowed, payment for the medical 338
condition included in that claim shall be charged to and paid from 339
the surplus fund created under section 4123.34 of the Revised 340
Code.341

       (B)(1) Except as provided in division (B)(2) of this section, 342
in claims other than those in which the employer is a 343
self-insuring employer, if the administrator determines under 344
division (A) of this section that a claimant is or is not entitled 345
to an award of compensation or benefits, the administrator shall 346
issue an order no later than twenty-eight days after the sending 347
of the notice under division (A) of this section, granting or 348
denying the payment of the compensation or benefits, or both as is 349
appropriate to the claimant. After conducting an investigation, if 350
the administrator determines that insufficient medical information 351
exists to grant or deny the payment of compensation, benefits, or 352
both to the claimant, the administrator may, with notice to both 353
parties, dismiss the claim without prejudice. Notwithstanding the 354
time limitation specified in this division for the issuance of an 355
order, if a medical examination of the claimant is required by 356
statute, the administrator promptly shall schedule the claimant 357
for that examination and shall issue an order no later than 358
twenty-eight days after receipt of the report of the examination. 359
The administrator shall notify the claimant and the employer of 360
the claimant and their respective representatives in writing of 361
the nature of the order and the amounts of compensation and 362
benefit payments involved. The employer or claimant may appeal the 363
order pursuant to division (C) of this section within fourteen 364
days after the date of the receipt of the order. The employer and 365
claimant may waive, in writing, their rights to an appeal under 366
this division.367

       (2) Notwithstanding the time limitation specified in division 368
(B)(1) of this section for the issuance of an order, if the 369
employer certifies a claim for payment of compensation or 370
benefits, or both, to a claimant, and the administrator has 371
completed the investigation of the claim, the payment of benefits 372
or compensation, or both, as is appropriate, shall commence upon 373
the later of the date of the certification or completion of the 374
investigation and issuance of the order by the administrator, 375
provided that the administrator shall issue the order no later 376
than the time limitation specified in division (B)(1) of this 377
section.378

       (3) If an appeal is made under division (B)(1) or (2) of this 379
section, the administrator shall forward the claim file to the 380
appropriate district hearing officer within seven days of the 381
appeal. In contested claims other than state fund claims, the 382
administrator shall forward the claim within seven days of the 383
administrator's receipt of the claim to the industrial commission, 384
which shall refer the claim to an appropriate district hearing 385
officer for a hearing in accordance with division (C) of this 386
section.387

       (C) If an employer or claimant timely appeals the order of 388
the administrator issued under division (B) of this section or in 389
the case of other contested claims other than state fund claims, 390
the commission shall refer the claim to an appropriate district 391
hearing officer according to rules the commission adopts under 392
section 4121.36 of the Revised Code. The district hearing officer 393
shall notify the parties and their respective representatives of 394
the time and place of the hearing.395

       The district hearing officer shall hold a hearing on a 396
disputed issue or claim within forty-five days after the filing of 397
the appeal under this division and issue a decision within seven 398
days after holding the hearing. The district hearing officer shall 399
notify the parties and their respective representatives in writing 400
of the order. Any party may appeal an order issued under this 401
division pursuant to division (D) of this section within fourteen 402
days after receipt of the order under this division.403

       (D) Upon the timely filing of an appeal of the order of the 404
district hearing officer issued under division (C) of this 405
section, the commission shall refer the claim file to an 406
appropriate staff hearing officer according to its rules adopted 407
under section 4121.36 of the Revised Code. The staff hearing 408
officer shall hold a hearing within forty-five days after the 409
filing of an appeal under this division and issue a decision 410
within seven days after holding the hearing under this division. 411
The staff hearing officer shall notify the parties and their 412
respective representatives in writing of the staff hearing 413
officer's order. Any party may appeal an order issued under this 414
division pursuant to division (E) of this section within fourteen 415
days after receipt of the order under this division.416

       (E) Upon the filing of a timely appeal of the order of the 417
staff hearing officer issued under division (D) of this section, 418
the commission or a designated staff hearing officer, on behalf of 419
the commission, shall determine whether the commission will hear 420
the appeal. If the commission or the designated staff hearing 421
officer decides to hear the appeal, the commission or the 422
designated staff hearing officer shall notify the parties and 423
their respective representatives in writing of the time and place 424
of the hearing. The commission shall hold the hearing within 425
forty-five days after the filing of the notice of appeal and, 426
within seven days after the conclusion of the hearing, the 427
commission shall issue its order affirming, modifying, or 428
reversing the order issued under division (D) of this section. The 429
commission shall notify the parties and their respective 430
representatives in writing of the order. If the commission or the 431
designated staff hearing officer determines not to hear the 432
appeal, within fourteen days after the expiration of the period in 433
which an appeal of the order of the staff hearing officer may be 434
filed as provided in division (D) of this section, the commission 435
or the designated staff hearing officer shall issue an order to 436
that effect and notify the parties and their respective 437
representatives in writing of that order.438

       Except as otherwise provided in this chapter and Chapters 439
4121., 4127., and 4131. of the Revised Code, any party may appeal 440
an order issued under this division to the court pursuant to 441
section 4123.512 of the Revised Code within sixty days after 442
receipt of the order, subject to the limitations contained in that 443
section.444

       (F) Every notice of an appeal from an order issued under 445
divisions (B), (C), (D), and (E) of this section shall state the 446
names of the claimant and employer, the number of the claim, the 447
date of the decision appealed from, and the fact that the 448
appellant appeals therefrom.449

       (G) All of the following apply to the proceedings under 450
divisions (C), (D), and (E) of this section:451

       (1) The parties shall proceed promptly and without 452
continuances except for good cause;453

       (2) The parties, in good faith, shall engage in the free 454
exchange of information relevant to the claim prior to the conduct 455
of a hearing according to the rules the commission adopts under 456
section 4121.36 of the Revised Code;457

       (3) The administrator is a party and may appear and 458
participate at all administrative proceedings on behalf of the 459
state insurance fund. However, in cases in which the employer is 460
represented, the administrator shall neither present arguments nor 461
introduce testimony that is cumulative to that presented or 462
introduced by the employer or the employer's representative. The 463
administrator may file an appeal under this section on behalf of 464
the state insurance fund; however, except in cases arising under 465
section 4123.343 of the Revised Code, the administrator only may 466
appeal questions of law or issues of fraud when the employer 467
appears in person or by representative.468

       (H) Except as provided in section 4121.63 of the Revised Code 469
and division (K) of this section, payments of compensation to a 470
claimant or on behalf of a claimant as a result of any order 471
issued under this chapter shall commence upon the earlier of the 472
following:473

       (1) Fourteen days after the date the administrator issues an 474
order under division (B) of this section, unless that order is 475
appealed;476

       (2) The date when the employer has waived the right to appeal 477
a decision issued under division (B) of this section;478

       (3) If no appeal of an order has been filed under this 479
section or to a court under section 4123.512 of the Revised Code, 480
the expiration of the time limitations for the filing of an appeal 481
of an order;482

       (4) The date of receipt by the employer of an order of a 483
district hearing officer, a staff hearing officer, or the 484
industrial commission issued under division (C), (D), or (E) of 485
this section.486

       (I) PaymentsExcept as otherwise provided in divisions (B) 487
and (C) of section 4123.66 of the Revised Code, payments of 488
medical benefits payable under this chapter or Chapter 4121., 489
4127., or 4131. of the Revised Code shall commence upon the 490
earlier of the following:491

       (1) The date of the issuance of the staff hearing officer's 492
order under division (D) of this section;493

       (2) The date of the final administrative or judicial 494
determination.495

       (J) The administrator shall charge the compensation payments 496
made in accordance with division (H) of this section or medical 497
benefits payments made in accordance with division (I) of this 498
section to an employer's experience immediately after the employer 499
has exhausted the employer's administrative appeals as provided in 500
this section or has waived the employer's right to an 501
administrative appeal under division (B) of this section, subject 502
to the adjustment specified in division (H) of section 4123.512 of 503
the Revised Code.504

       (K) Upon the final administrative or judicial determination 505
under this section or section 4123.512 of the Revised Code of an 506
appeal of an order to pay compensation, if a claimant is found to 507
have received compensation pursuant to a prior order which is 508
reversed upon subsequent appeal, the claimant's employer, if a 509
self-insuring employer, or the bureau, shall withhold from any 510
amount to which the claimant becomes entitled pursuant to any 511
claim, past, present, or future, under Chapter 4121., 4123., 512
4127., or 4131. of the Revised Code, the amount of previously paid 513
compensation to the claimant which, due to reversal upon appeal, 514
the claimant is not entitled, pursuant to the following criteria:515

       (1) No withholding for the first twelve weeks of temporary 516
total disability compensation pursuant to section 4123.56 of the 517
Revised Code shall be made;518

       (2) Forty per cent of all awards of compensation paid 519
pursuant to sections 4123.56 and 4123.57 of the Revised Code, 520
until the amount overpaid is refunded;521

       (3) Twenty-five per cent of any compensation paid pursuant to 522
section 4123.58 of the Revised Code until the amount overpaid is 523
refunded;524

       (4) If, pursuant to an appeal under section 4123.512 of the 525
Revised Code, the court of appeals or the supreme court reverses 526
the allowance of the claim, then no amount of any compensation 527
will be withheld.528

       The administrator and self-insuring employers, as 529
appropriate, are subject to the repayment schedule of this 530
division only with respect to an order to pay compensation that 531
was properly paid under a previous order, but which is 532
subsequently reversed upon an administrative or judicial appeal. 533
The administrator and self-insuring employers are not subject to, 534
but may utilize, the repayment schedule of this division, or any 535
other lawful means, to collect payment of compensation made to a 536
person who was not entitled to the compensation due to fraud as 537
determined by the administrator or the industrial commission.538

       (L) If a staff hearing officer or the commission fails to 539
issue a decision or the commission fails to refuse to hear an 540
appeal within the time periods required by this section, payments 541
to a claimant shall cease until the staff hearing officer or 542
commission issues a decision or hears the appeal, unless the 543
failure was due to the fault or neglect of the employer or the 544
employer agrees that the payments should continue for a longer 545
period of time.546

       (M) Except as otherwise provided in this section or section 547
4123.522 of the Revised Code, no appeal is timely filed under this 548
section unless the appeal is filed with the time limits set forth 549
in this section.550

       (N) No person who is not an employee of the bureau or 551
commission or who is not by law given access to the contents of a 552
claims file shall have a file in the person's possession.553

       (O) Upon application of a party who resides in an area in 554
which an emergency or disaster is declared, the industrial 555
commission and hearing officers of the commission may waive the 556
time frame within which claims and appeals of claims set forth in 557
this section must be filed upon a finding that the applicant was 558
unable to comply with a filing deadline due to an emergency or a 559
disaster. 560

       As used in this division:561

       (1) "Emergency" means any occasion or instance for which the 562
governor of Ohio or the president of the United States publicly 563
declares an emergency and orders state or federal assistance to 564
save lives and protect property, the public health and safety, or 565
to lessen or avert the threat of a catastrophe.566

       (2) "Disaster" means any natural catastrophe or fire, flood, 567
or explosion, regardless of the cause, that causes damage of 568
sufficient magnitude that the governor of Ohio or the president of 569
the United States, through a public declaration, orders state or 570
federal assistance to alleviate damage, loss, hardship, or 571
suffering that results from the occurrence.572

       Sec. 4123.53.  (A) The administrator of workers' compensation 573
or the industrial commission may require any employee claiming the 574
right to receive compensation to submit to a medical examination, 575
vocational evaluation, or vocational questionnaire at any time, 576
and from time to time, at a place reasonably convenient for the 577
employee, and as provided by the rules of the commission or the 578
administrator of workers' compensation. A claimant required by the 579
commission or administrator to submit to a medical examination or 580
vocational evaluation, at a point outside of the place of 581
permanent or temporary residence of the claimant, as provided in 582
this section, is entitled to have paid to the claimant by the 583
bureau of workers' compensation the necessary and actual expenses 584
on account of the attendance for the medical examination or 585
vocational evaluation after approval of the expense statement by 586
the bureau. Under extraordinary circumstances and with the 587
unanimous approval of the commission, if the commission requires 588
the medical examination or vocational evaluation, or with the 589
approval of the administrator, if the administrator requires the 590
medical examination or vocational evaluation, the bureau shall pay 591
an injured or diseased employee the necessary, actual, and 592
authorized expenses of treatment at a point outside the place of 593
permanent or temporary residence of the claimant.594

       (B) When an employee initially receives temporary total 595
disability compensation pursuant to section 4123.56 of the Revised 596
Code for a consecutive ninety-day period, the administrator shall 597
refer the employee to the bureau medical section for a medical 598
examination to determine the employee's continued entitlement to 599
such compensation, the employee's rehabilitation potential, and 600
the appropriateness of the medical treatment the employee is 601
receiving. The bureau medical section shall conduct the 602
examination not later than thirty days following the end of the 603
initial ninety-day period. If the medical examiner, upon an 604
initial or any subsequent examination recommended by the medical 605
examiner under this division, determines that the employee is 606
temporarily and totally impaired, the medical examiner shall 607
recommend a date when the employee should be reexamined. Upon the 608
issuance of the medical examination report containing a 609
recommendation for reexamination, the administrator shall schedule 610
an examination and, if at the date of reexamination the employee 611
is receiving temporary total disability compensation, the employee 612
shall be examined. The administrator shall adopt a rule, pursuant 613
to Chapter 119. of the Revised Code, permitting employers to waive 614
the administrator's scheduling of any such examinations.615

       (C) If, without good cause, an employee refuses to submit to 616
any medical examination or vocational evaluation scheduled 617
pursuant to this section or obstructs the same, or refuses to 618
complete and submit to the bureau or commission a vocational 619
questionnaire within thirty days after the bureau or commission 620
mails the request to complete and submit the questionnaire the 621
employee forfeits the employee's right to have his or herthe 622
employee's claim for compensation considered, if the claim is 623
pending before the bureau or commission, or to receive any payment 624
for compensation theretofore granted, is suspended duringor 625
benefits pertaining to the period of the refusal or obstruction. 626
The period of refusal or obstruction shall not toll any time frame 627
for the exercise of continuing jurisdiction by the administrator 628
or commission under section 4123.52 of the Revised Code.629
Notwithstanding this section, an employee's failure to submit to a 630
medical examination or vocational evaluation, or to complete and 631
submit a vocational questionnaire, shall not result in the 632
dismissal of the employee's claim.633

       (D) Medical examinations scheduled under this section do not 634
limit medical examinations provided for in other provisions of 635
this chapter or Chapter 4121. of the Revised Code.636

       Sec. 4123.651.  (A) The employer of a claimant who is injured 637
or disabled in the course of histhe claimant's employment may 638
require, without the approval of the administrator or the 639
industrial commission, that the claimant be examined by a 640
physician of the employer's choice one time upon any issue 641
asserted by the employee or a physician of the employee's choice 642
or which is to be considered by the commission. Any further 643
requests for medical examinations shall be made to the commission 644
which shall consider and rule on the request. The employer shall 645
pay the cost of any examinations initiated by the employer.646

       (B) The bureau of workers' compensation shall prepare a form 647
for the release of medical information, records, and reports 648
relative to the issues necessary for the administration of a claim 649
under this chapter. The claimant promptly shall provide a current 650
signed release of the information, records, and reports when 651
requested by the employer. The employer promptly shall provide 652
copies of all medical information, records, and reports to the 653
bureau and to the claimant or histhe claimant's representative 654
upon request.655

       (C) If, without good cause, an employee refuses to submit to 656
any examination scheduled under this section or refuses to release 657
or execute a release for any medical information, record, or 658
report that is required to be released under this section and 659
involves an issue pertinent to the condition alleged in the claim, 660
histhe employee forfeits the employee's right to have histhe 661
employee's claim for compensation or benefits considered, if his662
the employee's claim is pending before the administrator,or663
commission, or a district or staff hearing officer, or to receive 664
any payment for compensation or benefits previously granted, is 665
suspended duringpertaining to the period of refusal. The period 666
of refusal or obstruction shall not toll any time frame for the 667
exercise of continuing jurisdiction by the administrator or 668
commission under section 4123.52 of the Revised Code.669

       (D) No bureau or commission employee shall alter any medical 670
report obtained from a health care provider the bureau or 671
commission has selected or cause or request the health care 672
provider to alter or change a report. The bureau and commission 673
shall make any request for clarification of a health care 674
provider's report in writing and shall provide a copy of the 675
request to the affected parties and their representatives at the 676
time of making the request.677

       Sec. 4123.66.  (A) In addition to the compensation provided 678
for in this chapter, the administrator of workers' compensation 679
shall disburse and pay from the state insurance fund the amounts 680
for medical, nurse, and hospital services and medicine as the 681
administrator deems proper and, in case death ensues from the 682
injury or occupational disease, the administrator shall disburse 683
and pay from the fund reasonable funeral expenses in an amount not 684
to exceed fifty-five hundred dollars. The bureau of workers' 685
compensation shall reimburse anyone, whether dependent, volunteer, 686
or otherwise, who pays the funeral expenses of any employee whose 687
death ensues from any injury or occupational disease as provided 688
in this section. The administrator may adopt rules, with the 689
advice and consent of the bureau of workers' compensation board of 690
directors, with respect to furnishing medical, nurse, and hospital 691
service and medicine to injured or disabled employees entitled 692
thereto, and for the payment therefor. In case an injury or 693
industrial accident that injures an employee also causes damage to 694
the employee's eyeglasses, artificial teeth or other denture, or 695
hearing aid, or in the event an injury or occupational disease 696
makes it necessary or advisable to replace, repair, or adjust the 697
same, the bureau shall disburse and pay a reasonable amount to 698
repair or replace the same.699

       (B) The administrator, in the rules the administrator adopts 700
pursuant to division (A) of this section, may identify specified 701
medical services that are presumptively authorized and payable to 702
a provider who provides any of the services identified in, and 703
complies with the requirements set forth in, the rules the 704
administrator adopts for the services rendered. The administrator, 705
in the rules the administrator adopts under this division, shall 706
limit the payment for these services to only those services 707
rendered to a claimant during the time period beginning the date 708
the administrator issues an order pursuant to division (B) of 709
section 4123.511 of the Revised Code allowing a claim or allowing 710
an additional condition to which the services relate and ending 711
forty-five days after the date the order was issued.712

       If the claim or additional condition is ultimately disallowed 713
in a final administrative or judicial order, and if the employer 714
is a state fund employer who pays assessments into the surplus 715
fund account created under section 4123.34 of the Revised Code, 716
the payments for medical services made pursuant to this division 717
for that claim or condition shall be charged to and paid from the 718
surplus fund account and not charged through the state insurance 719
fund to the employer against whom the claim or additional 720
condition was filed.721

       (C) The administrator, in the rules the administrator adopts 722
pursuant to division (A) of this section, may adopt rules 723
specifying the circumstances under which the bureau may make 724
immediate payment for the first fill of prescription drugs for 725
medical conditions identified in an application for compensation 726
or benefits under section 4123.84 or 4123.85 of the Revised Code 727
that occurs prior to the date the administrator issues an initial 728
determination order under division (B) of this section. If the 729
claim is ultimately disallowed in a final administrative or 730
judicial order, and if the employer is a state fund employer who 731
pays assessments into the surplus fund account created under 732
section 4123.34 of the Revised Code, the payments for medical 733
services made pursuant to this division for the first fill of 734
prescription drugs shall be charged to and paid from the surplus 735
fund account and not charged through the state insurance fund to 736
the employer against whom the claim was filed.737

       (D) If, without good cause, an employee refuses to undertake 738
or unreasonably delays undertaking medical, nursing, and hospital 739
services and medicine that are ordered by the employee's treating 740
physician and that are payable under division (I) of section 741
4123.511 of the Revised Code, the employee forfeits the employee's 742
right to have the employee's claim for compensation or benefits 743
considered, if the claim is pending before the administrator or 744
the industrial commission, or to receive any payment for 745
compensation or benefits pertaining to the period of refusal. The 746
period of refusal or obstruction shall not toll any time frame for 747
the exercise of continuing jurisdiction by the administrator or 748
commission under section 4123.52 of the Revised Code.749

       (E)(1) If an employer or a welfare plan has provided to or on 750
behalf of an employee any benefits or compensation for an injury 751
or occupational disease and that injury or occupational disease is 752
determined compensable under this chapter, the employer or a 753
welfare plan may request that the administrator reimburse the 754
employer or welfare plan for the amount the employer or welfare 755
plan paid to or on behalf of the employee in compensation or 756
benefits. The administrator shall reimburse the employer or 757
welfare plan for the compensation and benefits paid if, at the 758
time the employer or welfare plan provides the benefits or 759
compensation to or on behalf of employee, the injury or 760
occupational disease had not been determined to be compensable 761
under this chapter and if the employee was not receiving 762
compensation or benefits under this chapter for that injury or 763
occupational disease. The administrator shall reimburse the 764
employer or welfare plan in the amount that the administrator 765
would have paid to or on behalf of the employee under this chapter 766
if the injury or occupational disease originally would have been 767
determined compensable under this chapter. If the employer is a 768
merit-rated employer, the administrator shall adjust the amount of 769
premium next due from the employer according to the amount the 770
administrator pays the employer. The administrator shall adopt 771
rules, in accordance with Chapter 119. of the Revised Code, to 772
implement this division.773

       (2) As used in this division, "welfare plan" has the same 774
meaning as in division (1) of 29 U.S.C.A. 1002.775

       (F)(1) As used in this division, "third party payer" means 776
any of the following entities that provides coverage to an 777
employee for medical, nurse, and hospital services or medicine:778

       (a) A person authorized to engage in the business of sickness 779
and accident insurance under Title XXXIX of the Revised Code;780

       (b) A person or governmental entity responsible for providing 781
coverage for medical services or items to an employee on a 782
self-insurance basis;783

       (c) A health insuring corporation holding a certificate of 784
authority under Chapter 1751. of the Revised Code;785

       (d) A group health plan as defined in 29 U.S.C. 1167;786

       (e) A service benefit plan as referenced in 42 U.S.C. 787
1396a(a)(25);788

       (f) A welfare plan as defined in division (E)(2) of this 789
section;790

       (g) Any other person or governmental entity that, by law, 791
contract, or agreement, is responsible for the payment or 792
processing of a claim for a medical item or service for an 793
employee.794

       (2) If the administrator has properly disbursed and paid any 795
amounts to or on behalf of an employee for medical, nurse, and 796
hospital services or medicine for an injury or occupational 797
disease and that injury or occupational disease is subsequently 798
determined to be noncompensable under this chapter or Chapter 799
4121., 4127., or 4131. of the Revised Code, the administrator may 800
request that the employee's third party payer reimburse the 801
administrator for the amount the administrator paid to or on 802
behalf of the employee for medical, nurse, and hospital services 803
or medicine. The employee and the employee's third party payer 804
shall cooperate with the administrator regarding requests for 805
reimbursements under this division, and the third party payer and 806
the administrator may share information as needed to facilitate 807
those requests. The third party payer shall reimburse the 808
administrator in the amount that the administrator disbursed and 809
paid to or on behalf of the employee under this chapter or Chapter 810
4121., 4127., or 4131. of the Revised Code. The administrator 811
shall credit any such amounts received to the surplus fund account 812
created in section 4123.34 of the Revised Code. The administrator 813
shall adopt rules, in accordance with Chapter 119. of the Revised 814
Code, to implement this division.815

       Sec. 4123.93.  As used in sections 4123.93 and 4123.931 of 816
the Revised Code:817

       (A) "Claimant" means a person who is eligible to receive 818
compensation, medical benefits, or death benefits under this 819
chapter or Chapter 4121., 4127., or 4131. of the Revised Code.820

       (B) "Statutory subrogee" means the administrator of workers' 821
compensation, a self-insuring employer, or an employer that 822
contracts for the direct payment of medical services pursuant to 823
division (L)(M) of section 4121.44 of the Revised Code.824

       (C) "Third party" means an individual, private insurer, 825
public or private entity, or public or private program that is or 826
may be liable to make payments to a person without regard to any 827
statutory duty contained in this chapter or Chapter 4121., 4127., 828
or 4131. of the Revised Code.829

       (D) "Subrogation interest" includes past, present, and 830
estimated future payments of compensation, medical benefits, 831
rehabilitation costs, or death benefits, and any other costs or 832
expenses paid to or on behalf of the claimant by the statutory 833
subrogee pursuant to this chapter or Chapter 4121., 4127., or 834
4131. of the Revised Code.835

       (E) "Net amount recovered" means the amount of any award, 836
settlement, compromise, or recovery by a claimant against a third 837
party, minus the attorney's fees, costs, or other expenses 838
incurred by the claimant in securing the award, settlement, 839
compromise, or recovery. "Net amount recovered" does not include 840
any punitive damages that may be awarded by a judge or jury.841

       (F) "Uncompensated damages" means the claimant's demonstrated 842
or proven damages minus the statutory subrogee's subrogation 843
interest.844

       Section 2. That existing sections 4121.44, 4121.441, 4121.63, 845
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93 of the Revised 846
Code are hereby repealed.847

       Section 3. This act applies to all claims pursuant to 848
Chapters 4121., 4123., 4127., and 4131. of the Revised Code 849
arising on and after the effective date of this act.850