No. 35305 (Amendment): Section R612-2-5. Regulation of Medical Practitioner Fees

(Amendment)

DAR File No.: 35305
Filed: 09/30/2011 08:12:08 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Pursuant to authority granted by Subsection 34A-2-407(9) of the Utah Workers' Compensation Act, this amendment constitutes the Utah Labor Commission's annual update of its regulation of medical fees for treatment of injured workers. The amendment incorporates by reference the most current relative value scale, coding guidelines, and medical fee guidelines. The amendment also adjusts conversion rates used in computing fees for various medical disciplines.

Summary of the rule or change:

This amendment incorporates by reference the: 1) Ingenix Essential RBRVS, 2011 1st Quarter Emergency Update (RBRVS); 2) Ingenix 2011 Current Procedural Coding Expert (CPT). Although the titles of these incorporated materials have changed from previous versions of this rule, their scope remains the same. The amendment incorporates by reference the Labor Commission 2012 Medical Fee Guidelines. The amendment reduces conversion rates for various medical disciplines in order to partially offset increases in the RBRVS, and modifies the conversion rate for pathology and laboratory services from a percentage to dollar factor. Finally, the amendment conforms the description of the conversion rate for restorative services to the provisions of the Commission's 2012 Medical Fee Guideline.

State statutory or constitutional authorization for this rule:

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

This rule or change incorporates by reference the following material:

• Updates Medical Fee Guidelines, published by Utah Labor Commission, 2012
• Updates Current Procedural Coding Expert, published by Ingenix, 2011
• Updates Essential RBRVS 1st Quarter Emergency Update, published by Ingenix, 2011

Anticipated cost or savings to:

the state budget:

The amendment will have no effect on the Labor Commission's cost in administering the Utah Workers' Compensation Act. With respect to the amendment's fiscal effect on the state in its capacity as an employer, changes incorporated within the RBRVS are offset to some extent by the reduction in conversion rates. The net effect will increase workers' compensation medical expense by approximately 2% and overall workers' compensation expense by approximately 1.3%.

local governments:

As a result of this amendment, local governments, in their capacities as employers, can anticipate a net increase in workers' compensation medical expenses of approximately 2%, which will in turn result in an increase in overall-workers' compensation expenses of approximately 1.3%.

small businesses:

As a result of this amendment, small businesses can anticipate a net increase in workers' compensation medical expenses of approximately 2%, which will in turn result in an increase in overall-workers' compensation expenses of approximately 1.3%.

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

Overall, physicians, therapists and others who provide medical services to injured workers can anticipate a 2% increase in payments for those services.

Compliance costs for affected persons:

The proposed rule does not impose any additional procedural requirements. It includes only a small increase in workers' compensation medical expenses, which should in turn result in only minimal compliance costs for affected persons.

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

With the assistance and approval of the Utah Workers' Compensation Advisory Council, this amendment carefully balances the cost to employers from slightly higher workers' compensation medical payments with the need to maintain a medical fee structure that will encourage medical providers to provide services to injured workers. While it is anticipated that the amendment will increase workers' compensation costs by approximately 1.3%, this modest increase is unlikely to have any significant fiscal impact on businesses, but is necessary to maintain the participation of medical providers within Utah's workers' compensation system.

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
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at [e-mail]

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:

11/14/2011

This rule may become effective on:

11/21/2011

Authorized by:

Sherrie Hayashi, Commissioner

RULE TEXT

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 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), 2010 edition]Ingenix Essential RBRVS, 2011 1st Quarter Emergency Update ("RBRVS"), as the method for calculating reimbursement and the [American Medical Association's CPT-4, 2010 edition, coding guidelines]Ingenix 2011 Current Procedural Coding Expert ("CPT").

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 2011 First Quarter RBRVS , 1761 Edition, are subject to the Utah Labor Commission's [2011] Medical Fee Guidelines and the following Labor Commission conversion factors for medical care rendered for a work-related injury or illness, effective December 1, 201[0]1: (Conversion Rates below EFFECTIVE December 1, 20[09]11, to be used with the RBRVS procedural Unit value as per specialty.)

Anesthesiology $4[1]0.00 (1 unit per 15 minutes of anesthesia);

Medicine, E and M $4[6]4.00 ;

Evaluation and Management codes 99201 - 99204 and 99211 - 99214 $4[6]4.00 ;

Pathology and Laboratory [150% of Utah's published Medicare carrier]$50.00;

Radiology $5[3]1.00;

Restorative Services $4[6]4.00 ;[, 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 $3[7]6.00;

All 20000 codes, codes 49505 thru 49525 and all 60000 codes of the CPT-4 coding guidelines $5[8]6.00.

3. Adopts and incorporates by this reference the Utah Labor Commission's 201[1]2 Medical Fee Guidelines, effective December 1, 201[0]1. The Utah Medical Fee Guidelines 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/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) to establish a reasonable fee for the procedure.

 

KEY: workers' compensation, fees, medical practitioner

Date of Enactment or Last Substantive Amendment: [November 22, 2010]2011

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

 

---