Administrative Code

Virginia Administrative Code
Title 16. Labor and Employment
Agency 30. Virginia Workers' Compensation Commission
1/21/2020

Chapter 60. Procedural Regulations Governing the Administration of Medical Costs Peer Review by the Regional Peer Review Committees under the Virginia Workers' Compensation Act

Part I
General Information

16VAC30-60-10. Authority for regulations.

Chapter 13 (§ 65.2-1300 et seq.) of Title 65.2 of the Code of Virginia vests authority in the Statewide Coordinating Committee for the development of a peer review program for services rendered by physicians who are paid in whole or in part pursuant to the Virginia Workers' Compensation Act.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 1.1, eff. Jan. 9, 1981; amended July 16, 1993.

16VAC30-60-20. Definitions.

The following words and terms, when used in these regulations, shall have the following meanings, unless the context clearly indicates otherwise:

"Commission" means the Virginia Workers' Compensation Commission.

"Peer review committee" means the appropriate regional peer review committee for a designated health systems area.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 1.2, eff. Jan. 9, 1981; amended July 16, 1993.

16VAC30-60-30. Purpose of regulations.

The Statewide Coordinating Committee has promulgated these regulations in order to establish standard procedures for the review of the appropriateness of the level, quality, duration, and cost of health care and health services provided by physicians to recipients of workers' compensation benefits.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 1.3, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-40. Implementation and administration of regulations.

These regulations shall be implemented and administered as follows:

1. The Statewide Coordinating Committee shall have the responsibility, subject to the approval of the commission, to promulgate, amend, and repeal, as appropriate, regulations for the implementation and administration of the peer review system; and

2. Each regional peer review committee shall administer these regulations for its respective health system area.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 1.4, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-50 to 16VAC30-60-60. [Reserved]

16VAC30-60-70. Severability.

If any provision of these regulations or the application thereof to any person or circumstances is held to be invalid, such invalidity shall not affect other provisions or application of any other part of these regulations which can be given effect without the invalid provisions or applications. To this end the provisions of these regulations are declared to be severable.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 1.7, eff. Jan. 9, 1981; July 16, 1993.

Part II
Initial Review

16VAC30-60-80. Requests for peer review.

A. Requests for peer review shall be made on a form prescribed by the Statewide Coordinating Committee and shall set forth or be accompanied by the following:

1. The name and address of the party requesting review;

2. The names of any physicians or clinics involved;

3. The name of the patient;

4. A description of the injury;

5. A description of the medical treatment, services, or costs complained of;

6. A description of where and when the treatment or services took place; and

7. A copy of any other relevant information forming the basis of the request for review, including any evidence indicating that the fees charged are different from those that prevail in the same community for similar treatment when the treatment is paid for by the injured person.

B. Requests for peer review shall be made to the Secretary of the Statewide Coordinating Committee. Requests may be submitted by the commission, a treating physician, any insurance company providing coverage for the cost of services paid for in whole or in part pursuant to the Workers' Compensation Act, or any employer.

C. The Secretary of the Statewide Coordinating Committee shall refer each completed request for review to the chairman of the appropriate regional peer review committee or to a member designated by the chairman.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-90. Defending party.

A. Any defending party subject to review under 16VAC30-60-80 shall be notified in writing by the Secretary of the Statewide Coordinating Committee.

B. The defending party shall be notified of peer review by certified mail, return receipt requested, within 30 days of the submission of a completed request for review to the Secretary. A copy of the notice shall be sent to the party requesting review.

C. The notice shall include:

1. A copy of the request for review;

2. A notice of the right of physician, insurer, employer, or counsel, to respond in writing and to appear before the peer review committee at an informal hearing; and

3. A notice of the requirement that a decision be reached by the peer review committee within 30 days after the informal hearing.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.2, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-100. Assignment for initial review.

A. Each request for review shall be assigned by the chairman of the peer review committee to an individual member for initial investigation and evaluation. The chairman shall establish rotating assignment procedures for equitable distribution among the committee members.

B. A committee member shall disqualify himself from participation in the review and decision of a particular request for review if ethically constrained by a conflict of interest. A committee member shall not participate in any review that relates to any care that he, or one of his associates, has rendered.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.3, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-110. Initial evaluation.

A. The committee member shall review the completed request for review, any response submitted by the defending party, and any additional information acquired during investigation.

B. The responsible peer review committee member may request additional information from the physician, the insurer/employer, or any other source that has relevant information. If necessary, the chairman of the peer review committee may request that the commission utilize its powers of investigation.

C. The committee member shall be prepared to make an oral evaluation of the request for review and recommended disposition at the informal hearing. The committee member or chairman has the discretion to resolve the matter in dispute with the consent of the parties and without the necessity of an informal hearing.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.4, eff. Jan. 9, 1981; July 16, 1993.

Part III
Informal Hearing Procedures

16VAC30-60-120. Informal fact finding.

Peer review committee consideration of each request for review shall be conducted as follows:

1. Meetings of the peer review committee shall be scheduled by the chairman. The informal hearing on a request for review shall be scheduled during a meeting of the peer review committee. The hearing shall be scheduled on the next open agenda and shall be held no later than 180 days after the date the request is received by the commission.

2. The Secretary of the Statewide Coordinating Committee shall notify the defending party by certified mail, return receipt requested, of the date of the informal hearing no less than 15 days before the hearing. A copy of the notice shall be sent to the party requesting review. In the event there is a request for a continuance of an informal hearing, the decision whether to grant the continuance shall be left to the discretion of the chairman.

3. Informal hearings on requests for review shall be conducted as follows:

a. A quorum shall consist of three members;

b. The chairman or his designated substitute shall preside;

c. The committee member who evaluated the request for review shall present orally his evaluation and recommendation;

d. The defending party shall be advised of any contrary factual basis or information in the committee's possession upon which the committee may rely in making an adverse decision;

e. The chairman shall allow the defending party, or counsel, an opportunity to present factual data, argument, or proofs for a period of time not exceeding 20 minutes;

f. Upon the conclusion of the presentation of all relevant information, the hearing will be closed;

g. The committee will, at a convenient time, conduct its deliberations outside the presence of the parties.

4. The peer review committee shall determine whether the physician has provided treatment or charged fees as prevail in the same community for injuries requiring similar treatment when the treatment is paid for by the injured person (§ 65.2-605 of the Code of Virginia).

5. Peer review committee proceedings, deliberations, and records constitute privileged communications as provided by § 65.2-1308 of the Code of Virginia. Committee communications, both oral and written, shall not be disclosed except as provided.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 3.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-130. Decision.

A. After deliberation, the peer review committee will vote on the recommended disposition, in the following manner:

1. The vote of the majority of the members present shall be adopted;

2. In the case of a tie vote, the review will be terminated and the decision deemed to be favorable to the defending party; and

3. Dissenting members may record their objections in writing.

B. If the decision is favorable to the physician, the peer review committee shall approve the payment of fees.

C. If the decision is unfavorable to the physician, the peer review committee shall set the physician's fee at a reasonable amount as described by the standard set out in § 65.2-605 of the Code of Virginia and, if the fee has already been paid by the party requesting review, require repayment by the physician of the excess amount.

D. Within 30 days of the informal hearing, the peer review committee shall prepare a statement, in writing, of the factual basis for its decision. Notice of the defending party's right of appeal shall be included in this statement. A copy of this statement shall be forwarded by the Secretary of the Statewide Coordinating Committee by certified mail, return receipt requested, to the defending party, the party requesting review, and the commission. The peer review committee file compiled under 16VAC30-60-110 of this chapter shall be forwarded to the commission

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 3.2, eff. Jan. 9, 1981; July 16, 1993.

Part IV
Appeal

16VAC30-60-140. Appeals.

Chapter 13 (§ 65.2-1300 et seq.) of Title 65.2 of the Code of Virginia and the Rules of the Commission shall govern all appeals.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 4.1, eff. Jan. 9, 1981; July 16, 1993.



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