The online versions of legislation provided on this website are not official. Enrolled bills are the final version passed by the Ohio General Assembly and presented to the Governor for signature. The official version of acts signed by the Governor are available from the Secretary of State's Office in the Continental Plaza, 180 East Broad St., Columbus.
|
H. B. No. 517 As IntroducedAs Introduced
129th General Assembly | Regular Session | 2011-2012 |
| |
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,
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93
of the Revised Code to allow the Administrator of
Workers' Compensation to pay for specified medical
benefits during an earlier time frame, to require
a workers' compensation claimant that refuses or
unreasonably delays treatment without good cause
to forfeit compensation and benefits during the
time period of refusal or delay, to make changes
to the health partnership program, and to make
other changes to the Workers' Compensation Law.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 4121.44, 4121.441, 4121.63,
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93 of the Revised
Code be amended to read as follows:
Sec. 4121.44. (A) The administrator of workers' compensation
shall oversee the implementation of the Ohio workers' compensation
qualified health plan system as established under section 4121.442
of the Revised Code.
(B) The administrator shall direct the implementation of the
health partnership program administered by the bureau as set forth
in section 4121.441 of the Revised Code. To implement the health
partnership program, the bureau:
(1) Shall certify one or more external vendors, which shall
be known as "managed care organizations," to provide medical
management and cost containment services in the health partnership
program for a period of two years beginning on the date of
certification, consistent with the standards established under
this section;
(2) May recertify external vendors for additional periods of
two years; and
(3) May integrate the certified vendors with bureau staff and
existing bureau services for purposes of operation and training to
allow the bureau to assume operation of the health partnership
program at the conclusion of the certification periods set forth
in division (B)(1) or (2) of this section.
(C) Any vendor selected shall demonstrate all of the
following:
(1) Arrangements and reimbursement agreements with a provider
panel including a substantial number of the medical, professional,
and pharmacy providers currently being utilized by claimants
participating in the health partnership program, selected on the
basis of access, quality, and cost.
(2) Ability to accept a common format of medical bill data in
an electronic fashion from any provider who wishes to submit
medical bill data in that form.
(3) A computer system able to handle the volume of medical
bills and willingness to customize that system to the bureau's
needs and to be operated by the vendor's staff, bureau staff, or
some combination of both staffs.
(4) A prescription drug system where pharmacies on a
statewide basis have access to the eligibility and pricing, at a
discounted rate, of all prescription drugs.
(5) A tracking system to record all telephone calls from
claimants and providers regarding the status of submitted medical
bills so as to be able to track each inquiry.
(6) Data processing capacity to absorb all of the bureau's
medical bill processing or at least that part of the processing
which the bureau arranges to delegate.
(7) Capacity to store, retrieve, array, simulate, and model
in a relational mode all of the detailed medical bill data so that
analysis can be performed in a variety of ways and so that the
bureau and its governing authority can make informed decisions.
(8) Wide variety of software programs which translate medical
terminology into standard codes, and which reveal if a provider is
manipulating the procedures codes, commonly called "unbundling."
(9) Necessary professional staff to conduct, at a minimum,
authorizations for treatment, medical necessity, utilization
review, concurrent review, post-utilization review, and have the
attendant computer system which supports such activity and
measures the outcomes and the savings.
(10) Management experience and flexibility to be able to
react quickly to the needs of the bureau in the case of required
change in federal or state requirements.
(D) For purposes of division (C)(1) of this section, any
provider panel used by a vendor shall provide reasonable access to
providers, deliver cost-effective treatment, and achieve quality
benchmarks established by the administrator.
(E)(1) Information contained in a vendor's application for
certification in the health partnership program, and other
information furnished to the bureau by a vendor for purposes of
obtaining certification or to comply with performance and
financial auditing requirements established by the administrator,
is for the exclusive use and information of the bureau in the
discharge of its official duties, and shall not be open to the
public or be used in any court in any proceeding pending therein,
unless the bureau is a party to the action or proceeding, but the
information may be tabulated and published by the bureau in
statistical form for the use and information of other state
departments and the public. No employee of the bureau, except as
otherwise authorized by the administrator, shall divulge any
information secured by the employee while in the employ of the
bureau in respect to a vendor's application for certification or
in respect to the business or other trade processes of any vendor
to any person other than the administrator or to the employee's
superior.
(2) Notwithstanding the restrictions imposed by division
(D)(E)(1) of this section, the governor, members of select or
standing committees of the senate or house of representatives, the
auditor of state, the attorney general, or their designees,
pursuant to the authority granted in this chapter and Chapter
4123. of the Revised Code, may examine any vendor application or
other information furnished to the bureau by the vendor. None of
those individuals shall divulge any information secured in the
exercise of that authority in respect to a vendor's application
for certification or in respect to the business or other trade
processes of any vendor to any person.
(E)(F) On and after January 1, 2001, a vendor shall not be
any insurance company holding a certificate of authority issued
pursuant to Title XXXIX of the Revised Code or any health insuring
corporation holding a certificate of authority under Chapter 1751.
of the Revised Code.
(F)(G) The administrator may limit freedom of choice of
health care provider or supplier by requiring, beginning with the
period set forth in division (B)(1) or (2) of this section the
forty-sixth day after the date of the injury or the forty-sixth
day after the beginning date for treatment for the occupational
disease, that claimants shall pay an appropriate out-of-plan
copayment for selecting a medical provider not within the provider
panel of a health partnership program vendor as provided for in
this section.
(G)(H) The administrator, six months prior to the expiration
of the bureau's certification or recertification of the vendor or
vendors as set forth in division (B)(1) or (2) of this section,
may certify and provide evidence to the governor, the speaker of
the house of representatives, and the president of the senate that
the existing bureau staff is able to match or exceed the
performance and outcomes of the external vendor or vendors and
that the bureau should be permitted to internally administer the
health partnership program upon the expiration of the
certification or recertification as set forth in division (B)(1)
or (2) of this section.
(H)(I) The administrator shall establish and operate a bureau
of workers' compensation health care data program. The
administrator shall develop reporting requirements from all
employees, employers and medical providers, medical vendors, and
plans that participate in the workers' compensation system. The
administrator shall do all of the following:
(1) Utilize the collected data to measure and perform
comparison analyses of costs, quality, appropriateness of medical
care, and effectiveness of medical care delivered by all
components of the workers' compensation system.;
(2) Compile data to support activities of the selected vendor
or vendors and annually to measure the outcomes and savings of
managed care organizations and providers in the health partnership
program.;
(3) Publish and report Report the compiled data on the
measures of outcomes and savings of the health partnership program
and submit the report to the president of the senate, the speaker
of the house of representatives, and the governor with the annual
report prepared under division (F)(3) of section 4121.12 of the
Revised Code. The administrator shall protect;
(4) Make the data compiled pursuant to division (I)(2) of
this section available to employers and the public;
(5) Protect the confidentiality of all proprietary pricing
data.
(I)(J) Any rehabilitation facility the bureau operates is
eligible for inclusion in the Ohio workers' compensation qualified
health plan system or the health partnership program under the
same terms as other providers within health care plans or the
program.
(J) In (K) Notwithstanding division (G) of this section, in
areas outside the state or within the state where no qualified
health plan or an inadequate number of providers within the health
partnership program exist, the administrator shall permit
employees to use a provider not within the provider panel of a
qualified health plan or health partnership program vendor,
including, if necessary, a nonplan or nonprogram health care
provider and shall pay the provider for the services or supplies
provided to or on behalf of an employee for an injury or
occupational disease that is compensable under this chapter or
Chapter 4123., 4127., or 4131. of the Revised Code on a fee
schedule the administrator adopts.
(K)(L) No health care provider, whether certified or not,
shall charge, assess, or otherwise attempt to collect from an
employee, employer, a managed care organization, or the bureau any
amount for covered services or supplies that is in excess of the
allowed amount paid by a managed care organization, the bureau, or
a qualified health plan.
(L)(M) The administrator shall permit any employer or group
of employers who agree to abide by the rules adopted under this
section and sections 4121.441 and 4121.442 of the Revised Code to
provide services or supplies to or on behalf of an employee for an
injury or occupational disease that is compensable under this
chapter or Chapter 4123., 4127., or 4131. of the Revised Code
through qualified health plans of the Ohio workers' compensation
qualified health plan system pursuant to section 4121.442 of the
Revised Code or through the health partnership program pursuant to
section 4121.441 of the Revised Code. No amount paid under the
qualified health plan system pursuant to section 4121.442 of the
Revised Code by an employer who is a state fund employer shall be
charged to the employer's experience or otherwise be used in
merit-rating or determining the risk of that employer for the
purpose of the payment of premiums under this chapter, and if the
employer is a self-insuring employer, the employer shall not
include that amount in the paid compensation the employer reports
under section 4123.35 of the Revised Code.
Sec. 4121.441. (A) The administrator of workers'
compensation, with the advice and consent of the bureau of
workers' compensation board of directors, shall adopt rules under
Chapter 119. of the Revised Code for the health care partnership
program administered by the bureau of workers' compensation to
provide medical, surgical, nursing, drug, hospital, and
rehabilitation services and supplies to an employee for an injury
or occupational disease that is compensable under this chapter or
Chapter 4123., 4127., or 4131. of the Revised Code.
The rules shall include, but are not limited to, the
following:
(1) Procedures for the resolution of medical disputes between
an employer and an employee, an employee and a provider, or an
employer and a provider, prior to an appeal under section 4123.511
of the Revised Code. Rules the administrator adopts pursuant to
division (A)(1) of this section may specify that the resolution
procedures shall not be used to resolve disputes concerning
medical services rendered that have been approved through standard
treatment guidelines, pathways, or presumptive authorization
guidelines.
(2) Prohibitions against discrimination against any category
of health care providers;
(3) Procedures for reporting injuries to employers and the
bureau by providers;
(4) Appropriate administrative and financial incentives to
reduce service cost and insure proper system utilization without
sacrificing the quality of service, including bonus payments to
providers who substantially exceed quality benchmarks established
by the administrator;
(5) Adequate methods of peer review, utilization review,
quality assurance, and dispute resolution to prevent, and provide
sanctions for, inappropriate, excessive or not medically necessary
treatment;
(6) A timely and accurate method of collection of necessary
information regarding medical and health care service and supply
costs, quality, and utilization to enable the administrator to
determine the effectiveness of the program;
(7) Provisions for necessary emergency medical treatment for
an injury or occupational disease provided by a health care
provider who is not part of the program;
(8) Discounted pricing for all in-patient and out-patient
medical services, all professional services, and all
pharmaceutical services;
(9) Provisions for provider referrals, pre-admission and
post-admission approvals, second surgical opinions, and other cost
management techniques;
(10) Antifraud mechanisms;
(11) Standards and criteria for the bureau to utilize in
certifying or recertifying a health care provider or a vendor for
participation in the health partnership program;
(12) Standards and criteria for the bureau to utilize in
penalizing or decertifying a health care provider or a vendor from
participation in the health partnership program.
(B) The administrator shall implement the health partnership
program according to the rules the administrator adopts under this
section for the provision and payment of medical, surgical,
nursing, drug, hospital, and rehabilitation services and supplies
to an employee for an injury or occupational disease that is
compensable under this chapter or Chapter 4123., 4127., or 4131.
of the Revised Code.
Sec. 4121.63. Claimants who the administrator of workers'
compensation determines could probably be rehabilitated to achieve
the goals established by section 4121.61 of the Revised Code and
who agree to undergo rehabilitation shall be paid living
maintenance payments for a period or periods which do not exceed
six months in the aggregate, unless review by the administrator or
the administrator's designee reveals that the claimant will be
benefited by an extension of such payments.
Living maintenance payments shall be paid in weekly amounts,
not to exceed the amount the claimant would receive if the
claimant were being compensated for temporary total disability,
but not less than fifty per cent of the current state average
weekly wage. Living maintenance payments shall commence at the
time the claimant begins to participate in an approved
rehabilitation program.
A claimant receiving living maintenance payments shall be
deemed to be temporarily totally disabled and shall receive no
payment of any type of compensation except as provided by division
(B) of section 4123.57 of the Revised Code for the periods during
which the claimant is receiving living maintenance payments.
If, without good cause, a claimant refuses to undertake or
unreasonably delays undertaking rehabilitation services,
counseling, or training in accordance with an approved
rehabilitation plan, the claimant forfeits the claimant's right to
have the claimant's claim for compensation or benefits considered,
if the claim is pending before the administrator or the industrial
commission, or to receive living maintenance payments or any other
payment for compensation or benefits pertaining to the period of
refusal. The period of refusal or obstruction shall not toll any
time frame for the exercise of continuing jurisdiction by the
administrator or commission under section 4123.52 of the Revised
Code.
Sec. 4123.511. (A) Within seven days after receipt of any
claim under this chapter, the bureau of workers' compensation
shall notify the claimant and the employer of the claimant of the
receipt of the claim and of the facts alleged therein. If the
bureau receives from a person other than the claimant written or
facsimile information or information communicated verbally over
the telephone indicating that an injury or occupational disease
has occurred or been contracted which may be compensable under
this chapter, the bureau shall notify the employee and the
employer of the information. If the information is provided
verbally over the telephone, the person providing the information
shall provide written verification of the information to the
bureau according to division (E) of section 4123.84 of the Revised
Code. The receipt of the information in writing or facsimile, or
if initially by telephone, the subsequent written verification,
and the notice by the bureau shall be considered an application
for compensation under section 4123.84 or 4123.85 of the Revised
Code, provided that the conditions of division (E) of section
4123.84 of the Revised Code apply to information provided verbally
over the telephone. Upon receipt of a claim, the bureau shall
advise the claimant of the claim number assigned and the
claimant's right to representation in the processing of a claim or
to elect no representation. If the bureau determines that a claim
is determined to be a compensable lost-time claim, the bureau
shall notify the claimant and the employer of the availability of
rehabilitation services. No bureau or industrial commission
employee shall directly or indirectly convey any information in
derogation of this right. This section shall in no way abrogate
the bureau's responsibility to aid and assist a claimant in the
filing of a claim and to advise the claimant of the claimant's
rights under the law.
The administrator of workers' compensation shall assign all
claims and investigations to the bureau service office from which
investigation and determination may be made most expeditiously.
The bureau shall investigate the facts concerning an injury
or occupational disease and ascertain such facts in whatever
manner is most appropriate and may obtain statements of the
employee, employer, attending physician, and witnesses in whatever
manner is most appropriate.
The administrator, with the advice and consent of the bureau
of workers' compensation board of directors, may adopt rules that
identify specified medical conditions that have a historical
record of being allowed whenever included in a claim. The
administrator may grant immediate allowance of any medical
condition identified in those rules upon the filing of a claim
involving that medical condition and may make immediate payment of
medical bills for any medical condition identified in those rules
that is included in a claim. If an employer contests the allowance
of a claim involving any medical condition identified in those
rules, and the claim is disallowed, payment for the medical
condition included in that claim shall be charged to and paid from
the surplus fund created under section 4123.34 of the Revised
Code.
(B)(1) Except as provided in division (B)(2) of this section,
in claims other than those in which the employer is a
self-insuring employer, if the administrator determines under
division (A) of this section that a claimant is or is not entitled
to an award of compensation or benefits, the administrator shall
issue an order no later than twenty-eight days after the sending
of the notice under division (A) of this section, granting or
denying the payment of the compensation or benefits, or both as is
appropriate to the claimant. After conducting an investigation, if
the administrator determines that insufficient medical information
exists to grant or deny the payment of compensation, benefits, or
both to the claimant, the administrator may, with notice to both
parties, dismiss the claim without prejudice. Notwithstanding the
time limitation specified in this division for the issuance of an
order, if a medical examination of the claimant is required by
statute, the administrator promptly shall schedule the claimant
for that examination and shall issue an order no later than
twenty-eight days after receipt of the report of the examination.
The administrator shall notify the claimant and the employer of
the claimant and their respective representatives in writing of
the nature of the order and the amounts of compensation and
benefit payments involved. The employer or claimant may appeal the
order pursuant to division (C) of this section within fourteen
days after the date of the receipt of the order. The employer and
claimant may waive, in writing, their rights to an appeal under
this division.
(2) Notwithstanding the time limitation specified in division
(B)(1) of this section for the issuance of an order, if the
employer certifies a claim for payment of compensation or
benefits, or both, to a claimant, and the administrator has
completed the investigation of the claim, the payment of benefits
or compensation, or both, as is appropriate, shall commence upon
the later of the date of the certification or completion of the
investigation and issuance of the order by the administrator,
provided that the administrator shall issue the order no later
than the time limitation specified in division (B)(1) of this
section.
(3) If an appeal is made under division (B)(1) or (2) of this
section, the administrator shall forward the claim file to the
appropriate district hearing officer within seven days of the
appeal. In contested claims other than state fund claims, the
administrator shall forward the claim within seven days of the
administrator's receipt of the claim to the industrial commission,
which shall refer the claim to an appropriate district hearing
officer for a hearing in accordance with division (C) of this
section.
(C) If an employer or claimant timely appeals the order of
the administrator issued under division (B) of this section or in
the case of other contested claims other than state fund claims,
the commission shall refer the claim to an appropriate district
hearing officer according to rules the commission adopts under
section 4121.36 of the Revised Code. The district hearing officer
shall notify the parties and their respective representatives of
the time and place of the hearing.
The district hearing officer shall hold a hearing on a
disputed issue or claim within forty-five days after the filing of
the appeal under this division and issue a decision within seven
days after holding the hearing. The district hearing officer shall
notify the parties and their respective representatives in writing
of the order. Any party may appeal an order issued under this
division pursuant to division (D) of this section within fourteen
days after receipt of the order under this division.
(D) Upon the timely filing of an appeal of the order of the
district hearing officer issued under division (C) of this
section, the commission shall refer the claim file to an
appropriate staff hearing officer according to its rules adopted
under section 4121.36 of the Revised Code. The staff hearing
officer shall hold a hearing within forty-five days after the
filing of an appeal under this division and issue a decision
within seven days after holding the hearing under this division.
The staff hearing officer shall notify the parties and their
respective representatives in writing of the staff hearing
officer's order. Any party may appeal an order issued under this
division pursuant to division (E) of this section within fourteen
days after receipt of the order under this division.
(E) Upon the filing of a timely appeal of the order of the
staff hearing officer issued under division (D) of this section,
the commission or a designated staff hearing officer, on behalf of
the commission, shall determine whether the commission will hear
the appeal. If the commission or the designated staff hearing
officer decides to hear the appeal, the commission or the
designated staff hearing officer shall notify the parties and
their respective representatives in writing of the time and place
of the hearing. The commission shall hold the hearing within
forty-five days after the filing of the notice of appeal and,
within seven days after the conclusion of the hearing, the
commission shall issue its order affirming, modifying, or
reversing the order issued under division (D) of this section. The
commission shall notify the parties and their respective
representatives in writing of the order. If the commission or the
designated staff hearing officer determines not to hear the
appeal, within fourteen days after the expiration of the period in
which an appeal of the order of the staff hearing officer may be
filed as provided in division (D) of this section, the commission
or the designated staff hearing officer shall issue an order to
that effect and notify the parties and their respective
representatives in writing of that order.
Except as otherwise provided in this chapter and Chapters
4121., 4127., and 4131. of the Revised Code, any party may appeal
an order issued under this division to the court pursuant to
section 4123.512 of the Revised Code within sixty days after
receipt of the order, subject to the limitations contained in that
section.
(F) Every notice of an appeal from an order issued under
divisions (B), (C), (D), and (E) of this section shall state the
names of the claimant and employer, the number of the claim, the
date of the decision appealed from, and the fact that the
appellant appeals therefrom.
(G) All of the following apply to the proceedings under
divisions (C), (D), and (E) of this section:
(1) The parties shall proceed promptly and without
continuances except for good cause;
(2) The parties, in good faith, shall engage in the free
exchange of information relevant to the claim prior to the conduct
of a hearing according to the rules the commission adopts under
section 4121.36 of the Revised Code;
(3) The administrator is a party and may appear and
participate at all administrative proceedings on behalf of the
state insurance fund. However, in cases in which the employer is
represented, the administrator shall neither present arguments nor
introduce testimony that is cumulative to that presented or
introduced by the employer or the employer's representative. The
administrator may file an appeal under this section on behalf of
the state insurance fund; however, except in cases arising under
section 4123.343 of the Revised Code, the administrator only may
appeal questions of law or issues of fraud when the employer
appears in person or by representative.
(H) Except as provided in section 4121.63 of the Revised Code
and division (K) of this section, payments of compensation to a
claimant or on behalf of a claimant as a result of any order
issued under this chapter shall commence upon the earlier of the
following:
(1) Fourteen days after the date the administrator issues an
order under division (B) of this section, unless that order is
appealed;
(2) The date when the employer has waived the right to appeal
a decision issued under division (B) of this section;
(3) If no appeal of an order has been filed under this
section or to a court under section 4123.512 of the Revised Code,
the expiration of the time limitations for the filing of an appeal
of an order;
(4) The date of receipt by the employer of an order of a
district hearing officer, a staff hearing officer, or the
industrial commission issued under division (C), (D), or (E) of
this section.
(I) Payments Except as otherwise provided in divisions (B)
and (C) of section 4123.66 of the Revised Code, payments of
medical benefits payable under this chapter or Chapter 4121.,
4127., or 4131. of the Revised Code shall commence upon the
earlier of the following:
(1) The date of the issuance of the staff hearing officer's
order under division (D) of this section;
(2) The date of the final administrative or judicial
determination.
(J) The administrator shall charge the compensation payments
made in accordance with division (H) of this section or medical
benefits payments made in accordance with division (I) of this
section to an employer's experience immediately after the employer
has exhausted the employer's administrative appeals as provided in
this section or has waived the employer's right to an
administrative appeal under division (B) of this section, subject
to the adjustment specified in division (H) of section 4123.512 of
the Revised Code.
(K) Upon the final administrative or judicial determination
under this section or section 4123.512 of the Revised Code of an
appeal of an order to pay compensation, if a claimant is found to
have received compensation pursuant to a prior order which is
reversed upon subsequent appeal, the claimant's employer, if a
self-insuring employer, or the bureau, shall withhold from any
amount to which the claimant becomes entitled pursuant to any
claim, past, present, or future, under Chapter 4121., 4123.,
4127., or 4131. of the Revised Code, the amount of previously paid
compensation to the claimant which, due to reversal upon appeal,
the claimant is not entitled, pursuant to the following criteria:
(1) No withholding for the first twelve weeks of temporary
total disability compensation pursuant to section 4123.56 of the
Revised Code shall be made;
(2) Forty per cent of all awards of compensation paid
pursuant to sections 4123.56 and 4123.57 of the Revised Code,
until the amount overpaid is refunded;
(3) Twenty-five per cent of any compensation paid pursuant to
section 4123.58 of the Revised Code until the amount overpaid is
refunded;
(4) If, pursuant to an appeal under section 4123.512 of the
Revised Code, the court of appeals or the supreme court reverses
the allowance of the claim, then no amount of any compensation
will be withheld.
The administrator and self-insuring employers, as
appropriate, are subject to the repayment schedule of this
division only with respect to an order to pay compensation that
was properly paid under a previous order, but which is
subsequently reversed upon an administrative or judicial appeal.
The administrator and self-insuring employers are not subject to,
but may utilize, the repayment schedule of this division, or any
other lawful means, to collect payment of compensation made to a
person who was not entitled to the compensation due to fraud as
determined by the administrator or the industrial commission.
(L) If a staff hearing officer or the commission fails to
issue a decision or the commission fails to refuse to hear an
appeal within the time periods required by this section, payments
to a claimant shall cease until the staff hearing officer or
commission issues a decision or hears the appeal, unless the
failure was due to the fault or neglect of the employer or the
employer agrees that the payments should continue for a longer
period of time.
(M) Except as otherwise provided in this section or section
4123.522 of the Revised Code, no appeal is timely filed under this
section unless the appeal is filed with the time limits set forth
in this section.
(N) No person who is not an employee of the bureau or
commission or who is not by law given access to the contents of a
claims file shall have a file in the person's possession.
(O) Upon application of a party who resides in an area in
which an emergency or disaster is declared, the industrial
commission and hearing officers of the commission may waive the
time frame within which claims and appeals of claims set forth in
this section must be filed upon a finding that the applicant was
unable to comply with a filing deadline due to an emergency or a
disaster.
As used in this division:
(1) "Emergency" means any occasion or instance for which the
governor of Ohio or the president of the United States publicly
declares an emergency and orders state or federal assistance to
save lives and protect property, the public health and safety, or
to lessen or avert the threat of a catastrophe.
(2) "Disaster" means any natural catastrophe or fire, flood,
or explosion, regardless of the cause, that causes damage of
sufficient magnitude that the governor of Ohio or the president of
the United States, through a public declaration, orders state or
federal assistance to alleviate damage, loss, hardship, or
suffering that results from the occurrence.
Sec. 4123.53. (A) The administrator of workers' compensation
or the industrial commission may require any employee claiming the
right to receive compensation to submit to a medical examination,
vocational evaluation, or vocational questionnaire at any time,
and from time to time, at a place reasonably convenient for the
employee, and as provided by the rules of the commission or the
administrator of workers' compensation. A claimant required by the
commission or administrator to submit to a medical examination or
vocational evaluation, at a point outside of the place of
permanent or temporary residence of the claimant, as provided in
this section, is entitled to have paid to the claimant by the
bureau of workers' compensation the necessary and actual expenses
on account of the attendance for the medical examination or
vocational evaluation after approval of the expense statement by
the bureau. Under extraordinary circumstances and with the
unanimous approval of the commission, if the commission requires
the medical examination or vocational evaluation, or with the
approval of the administrator, if the administrator requires the
medical examination or vocational evaluation, the bureau shall pay
an injured or diseased employee the necessary, actual, and
authorized expenses of treatment at a point outside the place of
permanent or temporary residence of the claimant.
(B) When an employee initially receives temporary total
disability compensation pursuant to section 4123.56 of the Revised
Code for a consecutive ninety-day period, the administrator shall
refer the employee to the bureau medical section for a medical
examination to determine the employee's continued entitlement to
such compensation, the employee's rehabilitation potential, and
the appropriateness of the medical treatment the employee is
receiving. The bureau medical section shall conduct the
examination not later than thirty days following the end of the
initial ninety-day period. If the medical examiner, upon an
initial or any subsequent examination recommended by the medical
examiner under this division, determines that the employee is
temporarily and totally impaired, the medical examiner shall
recommend a date when the employee should be reexamined. Upon the
issuance of the medical examination report containing a
recommendation for reexamination, the administrator shall schedule
an examination and, if at the date of reexamination the employee
is receiving temporary total disability compensation, the employee
shall be examined. The administrator shall adopt a rule, pursuant
to Chapter 119. of the Revised Code, permitting employers to waive
the administrator's scheduling of any such examinations.
(C) If, without good cause, an employee refuses to submit to
any medical examination or vocational evaluation scheduled
pursuant to this section or obstructs the same, or refuses to
complete and submit to the bureau or commission a vocational
questionnaire within thirty days after the bureau or commission
mails the request to complete and submit the questionnaire the
employee forfeits the employee's right to have his or her the
employee's claim for compensation considered, if the claim is
pending before the bureau or commission, or to receive any payment
for compensation theretofore granted, is suspended during or
benefits pertaining to the period of the refusal or obstruction.
The period of refusal or obstruction shall not toll any time frame
for the exercise of continuing jurisdiction by the administrator
or commission under section 4123.52 of the Revised Code.
Notwithstanding this section, an employee's failure to submit to a
medical examination or vocational evaluation, or to complete and
submit a vocational questionnaire, shall not result in the
dismissal of the employee's claim.
(D) Medical examinations scheduled under this section do not
limit medical examinations provided for in other provisions of
this chapter or Chapter 4121. of the Revised Code.
Sec. 4123.651. (A) The employer of a claimant who is injured
or disabled in the course of
his the claimant's employment may
require, without the approval of the administrator or the
industrial commission, that the claimant be examined by a
physician of the employer's choice one time upon any issue
asserted by the employee or a physician of the employee's choice
or which is to be considered by the commission. Any further
requests for medical examinations shall be made to the commission
which shall consider and rule on the request. The employer shall
pay the cost of any examinations initiated by the employer.
(B) The bureau of workers' compensation shall prepare a form
for the release of medical information, records, and reports
relative to the issues necessary for the administration of a claim
under this chapter. The claimant promptly shall provide a current
signed release of the information, records, and reports when
requested by the employer. The employer promptly shall provide
copies of all medical information, records, and reports to the
bureau and to the claimant or his the claimant's representative
upon request.
(C) If, without good cause, an employee refuses to submit to
any examination scheduled under this section or refuses to release
or execute a release for any medical information, record, or
report that is required to be released under this section and
involves an issue pertinent to the condition alleged in the claim,
his the employee forfeits the employee's right to have his the
employee's claim for compensation or benefits considered, if his
the employee's claim is pending before the administrator, or
commission, or a district or staff hearing officer, or to receive
any payment for compensation or benefits previously granted, is
suspended during pertaining to the period of refusal. The period
of refusal or obstruction shall not toll any time frame for the
exercise of continuing jurisdiction by the administrator or
commission under section 4123.52 of the Revised Code.
(D) No bureau or commission employee shall alter any medical
report obtained from a health care provider the bureau or
commission has selected or cause or request the health care
provider to alter or change a report. The bureau and commission
shall make any request for clarification of a health care
provider's report in writing and shall provide a copy of the
request to the affected parties and their representatives at the
time of making the request.
Sec. 4123.66. (A) In addition to the compensation provided
for in this chapter, the administrator of workers' compensation
shall disburse and pay from the state insurance fund the amounts
for medical, nurse, and hospital services and medicine as the
administrator deems proper and, in case death ensues from the
injury or occupational disease, the administrator shall disburse
and pay from the fund reasonable funeral expenses in an amount not
to exceed fifty-five hundred dollars. The bureau of workers'
compensation shall reimburse anyone, whether dependent, volunteer,
or otherwise, who pays the funeral expenses of any employee whose
death ensues from any injury or occupational disease as provided
in this section. The administrator may adopt rules, with the
advice and consent of the bureau of workers' compensation board of
directors, with respect to furnishing medical, nurse, and hospital
service and medicine to injured or disabled employees entitled
thereto, and for the payment therefor. In case an injury or
industrial accident that injures an employee also causes damage to
the employee's eyeglasses, artificial teeth or other denture, or
hearing aid, or in the event an injury or occupational disease
makes it necessary or advisable to replace, repair, or adjust the
same, the bureau shall disburse and pay a reasonable amount to
repair or replace the same.
(B) The administrator, in the rules the administrator adopts
pursuant to division (A) of this section, may identify specified
medical services that are presumptively authorized and payable to
a provider who provides any of the services identified in, and
complies with the requirements set forth in, the rules the
administrator adopts for the services rendered. The administrator,
in the rules the administrator adopts under this division, shall
limit the payment for these services to only those services
rendered to a claimant during the time period beginning the date
the administrator issues an order pursuant to division (B) of
section 4123.511 of the Revised Code allowing a claim or allowing
an additional condition to which the services relate and ending
forty-five days after the date the order was issued.
If the claim or additional condition is ultimately disallowed
in a final administrative or judicial order, and if the employer
is a state fund employer who pays assessments into the surplus
fund account created under section 4123.34 of the Revised Code,
the payments for medical services made pursuant to this division
for that claim or condition shall be charged to and paid from the
surplus fund account and not charged through the state insurance
fund to the employer against whom the claim or additional
condition was filed.
(C) The administrator, in the rules the administrator adopts
pursuant to division (A) of this section, may adopt rules
specifying the circumstances under which the bureau may make
immediate payment for the first fill of prescription drugs for
medical conditions identified in an application for compensation
or benefits under section 4123.84 or 4123.85 of the Revised Code
that occurs prior to the date the administrator issues an initial
determination order under division (B) of this section. If the
claim is ultimately disallowed in a final administrative or
judicial order, and if the employer is a state fund employer who
pays assessments into the surplus fund account created under
section 4123.34 of the Revised Code, the payments for medical
services made pursuant to this division for the first fill of
prescription drugs shall be charged to and paid from the surplus
fund account and not charged through the state insurance fund to
the employer against whom the claim was filed.
(D) If, without good cause, an employee refuses to undertake
or unreasonably delays undertaking medical, nursing, and hospital
services and medicine that are ordered by the employee's treating
physician and that are payable under division (I) of section
4123.511 of the Revised Code, the employee forfeits the employee's
right to have the employee's claim for compensation or benefits
considered, if the claim is pending before the administrator or
the industrial commission, or to receive any payment for
compensation or benefits pertaining to the period of refusal. The
period of refusal or obstruction shall not toll any time frame for
the exercise of continuing jurisdiction by the administrator or
commission under section 4123.52 of the Revised Code.
(E)(1) If an employer or a welfare plan has provided to or on
behalf of an employee any benefits or compensation for an injury
or occupational disease and that injury or occupational disease is
determined compensable under this chapter, the employer or a
welfare plan may request that the administrator reimburse the
employer or welfare plan for the amount the employer or welfare
plan paid to or on behalf of the employee in compensation or
benefits. The administrator shall reimburse the employer or
welfare plan for the compensation and benefits paid if, at the
time the employer or welfare plan provides the benefits or
compensation to or on behalf of employee, the injury or
occupational disease had not been determined to be compensable
under this chapter and if the employee was not receiving
compensation or benefits under this chapter for that injury or
occupational disease. The administrator shall reimburse the
employer or welfare plan in the amount that the administrator
would have paid to or on behalf of the employee under this chapter
if the injury or occupational disease originally would have been
determined compensable under this chapter. If the employer is a
merit-rated employer, the administrator shall adjust the amount of
premium next due from the employer according to the amount the
administrator pays the employer. The administrator shall adopt
rules, in accordance with Chapter 119. of the Revised Code, to
implement this division.
(2) As used in this division, "welfare plan" has the same
meaning as in division (1) of 29 U.S.C.A. 1002.
(F)(1) As used in this division, "third party payer" means
any of the following entities that provides coverage to an
employee for medical, nurse, and hospital services or medicine:
(a) A person authorized to engage in the business of sickness
and accident insurance under Title XXXIX of the Revised Code;
(b) A person or governmental entity responsible for providing
coverage for medical services or items to an employee on a
self-insurance basis;
(c) A health insuring corporation holding a certificate of
authority under Chapter 1751. of the Revised Code;
(d) A group health plan as defined in 29 U.S.C. 1167;
(e) A service benefit plan as referenced in 42 U.S.C.
1396a(a)(25);
(f) A welfare plan as defined in division (E)(2) of this
section;
(g) Any other person or governmental entity that, by law,
contract, or agreement, is responsible for the payment or
processing of a claim for a medical item or service for an
employee.
(2) If the administrator has properly disbursed and paid any
amounts to or on behalf of an employee for medical, nurse, and
hospital services or medicine for an injury or occupational
disease and that injury or occupational disease is subsequently
determined to be noncompensable under this chapter or Chapter
4121., 4127., or 4131. of the Revised Code, the administrator may
request that the employee's third party payer reimburse the
administrator for the amount the administrator paid to or on
behalf of the employee for medical, nurse, and hospital services
or medicine. The employee and the employee's third party payer
shall cooperate with the administrator regarding requests for
reimbursements under this division, and the third party payer and
the administrator may share information as needed to facilitate
those requests. The third party payer shall reimburse the
administrator in the amount that the administrator disbursed and
paid to or on behalf of the employee under this chapter or Chapter
4121., 4127., or 4131. of the Revised Code. The administrator
shall credit any such amounts received to the surplus fund account
created in section 4123.34 of the Revised Code. The administrator
shall adopt rules, in accordance with Chapter 119. of the Revised
Code, to implement this division.
Sec. 4123.93. As used in sections 4123.93 and 4123.931 of
the Revised Code:
(A) "Claimant" means a person who is eligible to receive
compensation, medical benefits, or death benefits under this
chapter or Chapter 4121., 4127., or 4131. of the Revised Code.
(B) "Statutory subrogee" means the administrator of workers'
compensation, a self-insuring employer, or an employer that
contracts for the direct payment of medical services pursuant to
division (L)(M) of section 4121.44 of the Revised Code.
(C) "Third party" means an individual, private insurer,
public or private entity, or public or private program that is or
may be liable to make payments to a person without regard to any
statutory duty contained in this chapter or Chapter 4121., 4127.,
or 4131. of the Revised Code.
(D) "Subrogation interest" includes past, present, and
estimated future payments of compensation, medical benefits,
rehabilitation costs, or death benefits, and any other costs or
expenses paid to or on behalf of the claimant by the statutory
subrogee pursuant to this chapter or Chapter 4121., 4127., or
4131. of the Revised Code.
(E) "Net amount recovered" means the amount of any award,
settlement, compromise, or recovery by a claimant against a third
party, minus the attorney's fees, costs, or other expenses
incurred by the claimant in securing the award, settlement,
compromise, or recovery. "Net amount recovered" does not include
any punitive damages that may be awarded by a judge or jury.
(F) "Uncompensated damages" means the claimant's demonstrated
or proven damages minus the statutory subrogee's subrogation
interest.
Section 2. That existing sections 4121.44, 4121.441, 4121.63,
4123.511, 4123.53, 4123.651, 4123.66, and 4123.93 of the Revised
Code are hereby repealed.
Section 3. This act applies to all claims pursuant to
Chapters 4121., 4123., 4127., and 4131. of the Revised Code
arising on and after the effective date of this act.
|
|