Labor Commission, Industrial Accidents

Section R612-2-5

Regulation of Medical Practitioner Fees

Notice of Proposed Rule

(Amendment)

DAR File No.: 33007
Filed: 09/30/2009 03:20:54 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The proposed amendments to Section R612-2-5: 1) update the Labor Commission's standards for fees paid to medical providers providing care to injured workers under Utah's workers' compensation system; 2) set forth the options for seeking payment for medical procedures not included in the Commission's existing standards; and 3) make other nonsubstantive changes to simplify and clarify the language of the existing rule.

Summary of the rule or change:

The proposed amendment removes an unnecessary listing of specific medical services that are subject to the rule and eliminates a reference to Ingenex methodology for computation of reimbursement rates for some pathology and laboratory services. The amendment incorporates by reference current versions of the Resource-Based Relative Value Scale (RBRVS), the American Medical Association's CPT-4 coding guidelines, and the Labor Commission's Medical Fee Guidelines. The amendment updates a reference to the Labor Commission's web site. Finally, the rule identifies existing methods by which injured workers and their medical providers can seek payment for medical services that are not otherwise addressed by this rule.

State statutory or constitutional authorization for this rule:

• Section 34A-3-101 et seq.
• Section 34A-1-104
• Section 34A-2-101 et seq.

This rule or change incorporates by reference the following material:

• Updates: 2009-2010 Medical Fee Guidelines, 12/01/2009
• Updates: The Resource-Based Relative Value Scale (RBRVS), 2009
• Updates: CPT-4 Professional Edition, 2009

Anticipated cost or savings to:

the state budget:

This proposed amendment will not impose any additional implementation or regulatory costs on the Labor Commission, which is the state agency charged with administering and enforcing Utah's workers' compensation system. The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 1.4% as a result of adoption of the updated RBRVS and CPT standards. The Commission presumes that this increase will be passed on to the state in increased workers' compensation insurance premiums.

local governments:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 1.4% as a result of adoption of the updated RBRVS and CPT standards. The Commission presumes that this increase will be passed on to local governments in increased workers' compensation insurance premiums.

small businesses:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 1.4% as a result of adoption of the updated RBRVS and CPT standards. The Commission presumes that this increase will be passed on to small businesses in increased workers' compensation insurance premiums.

persons other than small businesses, businesses, or local governmental entities:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 1.4% as a result of adoption of the updated RBRVS and CPT standards. The Commission presumes that this increase will be passed on to employers in increased workers' compensation insurance premiums.

Compliance costs for affected persons:

Workers' compensation insurance carriers and those providing medical services to injured workers will be affected by the proposed amendment. Because the RBRVS and CPT systems are already used throughout the health care industry, insurance carriers and medical providers already receive and use updates to those systems. The Commission does not anticipate that the updates required by this rule amendment will result in any additional compliance costs for those entities.

Comments by the department head on the fiscal impact the rule may have on businesses:

The workers' compensation system uses the same relative value (RBRVS) and coding (CPT) systems that are generally used throughout the health industry. Periodically, the RBRVS and CPT systems are updated. It is therefore necessary for the Commission to also adopt those changes in order to 1) avoid confusion and 2) provide adequate payment for medical care provided to injured workers. This year, the modifications to the RBRVS and CPT will result in increased payments for some medical services. These increases will be factored in to workers' compensation insurance premiums, but they are relatively small and may be offset by reductions in other factors.

Sherrie Hayashi, Commissioner.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Labor Commission
Industrial Accidents
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Larry Bunkall at the above address, by phone at 801-530-6988, by FAX at 801-530-6844, or by Internet E-mail at lbunkall@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

11/16/2009

This rule may become effective on:

11/23/2009

Authorized by:

Sherrie Hayashi, Commissioner

R612. Labor Commission, Industrial Accidents.

R612-2. Workers' Compensation Rules-Health Care Providers.

R612-2-5. Regulation of Medical Practitioner Fees.

Pursuant to Section 34A-2-407 (9):

A. The Labor Commission of Utah:

1. Establishes and regulates fees and other charges for medical[, surgical, nursing, physical and occupational therapy, mental health, chiropractic, naturopathic, and osteopathic services, or any other area of the healing arts] provider services as required for the treatment of a work-related injury or illness.

2. Adopts and by this reference incorporates the National Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) "Resource-Based Relative Value Scale" (RBRVS), 200[8]9 edition, as the method for calculating reimbursement and the American Medical Association's CPT-4, 200[8]9 edition, coding guidelines.

a. The non-facility total unit value will apply in calculating the reimbursement, except that procedures provided in a facility setting shall be reimbursed at the facility total unit value and the facility may bill a separate facility charge.

b. The CPT-4 coding guidelines and RBRVS are subject to the Utah Labor Commission's 2009 - 2010 Medical Fee Guidelines [and Codes ]and the following Labor Commission conversion factors for medical care rendered for a work-related injury or illness, effective [July]December 1, 200[8]9: (Conversion Rates below EFFECTIVE [July]December 1, 200[8]9, to be used with the RBRVS procedural Unit value as per specialty.)

Anesthesiology $41.00 (1 unit per 15 minutes of anesthesia);

Medicine, E and M $46.00

Evaluation and Management codes 99201 - 99204 and 99211 - 99214 $46.00

Pathology and Laboratory [The current RBRVS identifies values for specific codes that require Pathologist services. All other reimbursement rates for laboratory and pathology codes will be determined by the Ingenix ga-filled methodology. $52.00;]150% of Utah's published Medicare carrier

Radiology $53.00;

Restorative Services $46.00, with Utah code 97001 and 97003 at a 1.5 relative value unit and Utah code 97002 and 97004 at a 1.0 of relative value unit.

Surgery $37.00;

All 20000 codes, codes 49505 thru 49525 and all 60000 codes of the CPT-4 coding guidelines $58.00.

3. Adopts and incorporates by this reference the Utah Labor Commission's 2009 - 2010 Medical Fee Guidelines[and Codes], [as of]effective [July]December 1, 200[8]9. The Utah Medical Fee Guidelines[and Codes] can be obtained from the division for a fee sufficient to recover costs of development, printing, and mailing or can be downloaded at the Labor Commission's website at [http://laborcommission.utah.gov/IndustrialAccidents/pdfs/Med%20Fee%20Guidelines%20%202007%2008-07.pdf]http://laborcommission.utah.gov/Provider%20Page.htm1#WorkersCompensation.

4. Decides appropriate billing procedure codes when disputes arise between the medical practitioner and the employer or its insurance carrier. In no instance will the medical practitioner bill both the employer and the insurance carrier.

B. Employees cannot be billed for treatment of their work-related injuries or illnesses.

C. Discounting from the fees established by the Labor Commission is allowed only through specific contracts between a medical provider and a payor for treatment of work-related injury or illness.

D. Restocking fee 15%. Rule R612-2-16 covers the restocking fee.

E. Dental fees are not published. Rule R612-2-18 covers dental injuries.

F. Ambulance fees are not published. Rule R612-2-19 covers ambulance charges.

G. For procedures not covered by other provisions of this rule, medical providers have three options.

1. Medical providers may request preauthorization for a procedure from the insurance carrier.

2. Medical providers may present evidence to Medical Fee Committee for incorporating a procedure into the Commission's fee schedule. However, such incorporation will have prospective effect only.

3. Medical providers may apply for hearing before the Commission's Adjudication Division pursuant to Subsection 34A-2-801(1)(c) and Subsection 34A-2-407(9)(f) to establish a reasonable fee for the procedure.

 

KEY: workers' compensation, fees, medical practitioner

Date of Enactment or Last Substantive Amendment: [December 8, 2008]2009

Notice of Continuation: April 28, 2008

Authorizing, and Implemented or Interpreted Law: 34A-2-101 et seq.; 34A-3-101 et seq.; 34A-1-104