Limiting Opioid use in Workers' Compensation Cases

The Workers' Compensation Health Care Services Rules were amended to include provisions placing limitations on physicians’ ability to receive reimbursement for opioid treatment beyond 90 days if certain requirements are not met.  The requirements were implemented to address the problems associated with long-term opioid use and limit potential addiction issues. 

To receive reimbursement under Rule 418.101008a a physician must provide a written report to the payer within 90 days of the initial opioid prescription andevery 90 days thereafter.  The written report must include:

1. A review and analysis of the patient’s prior medical history, including information received from automated prescription drug monitoring programs, to determine if there is a history of narcotic use or duplicate prescriptions.
2. A summary of the conservative treatment measures used and why those measures were ineffective or contraindicated.
3. A summary of the screening methods used to determine whether there is an increased risk of abuse or negative outcomes including a history of alcohol or substance abuse.  A copy of the screening results should be attached.
4. A summary of the treatment plan including the goals, progress, non-opioid pain management modalities used, and a plan for weaning the patient off the opioid medication.
5. A summary of periodic urine drug screen results.

An opioid treatment agreement outlining the risks and benefits of use, conditions under which the medication is prescribed, and responsibilities of the physician and patient, must be signed by the patient and physician and attached to the written report.  The opioid treatment agreement must be updated every six months.  

Physicians are permitted to bill for the services required to comply with this rule. 

Reimbursement for prescribing and dispensing opioid medications will be denied if the requirements stated in Rule 418.101008a are not met.  However, the denial can only occur after a “reasonable” period of time is provided for weaning the patient off the opioid medication and alternative methods of pain management are offered.