Indiana will have a workers compensation medical fee schedule beginning 07/01/14. A billing review service must adhere to IC § 22-3-3-5.2.
Reimbursement to medical service facility based on Medicare’s reimbursement rate
HEA 1320 enacted legislation governing payments made under the Act by an employer or an employer’s insurance carrier to a medical service facility beginning July 1, 2014. Under the Act, medical service facility is defined as only the following: (1) a hospital (as defined in Ind. Code § 16-18-2-179); (2) a hospital-based health facility (as defined in Ind. Code § 16-18-2-180); or (3) a medical center (as defined in Ind. Code § 16-18-2-223.4). Ind. Code § 22-3-6-1(j). The legislation imposed a fee schedule that places a cap on reimbursement at 200 percent of Medicare’s reimbursement rate for treatments or procedures by a medical service facility to a workers compensation claimant. Id. at § 22-3-3-5.2(b)(2); see also § 22-3-6-1(k)(2)(B) (defining pecuniary liability). Such fee schedule is applicable unless the amount of reimbursement is otherwise negotiated between the medical service facility and any of the following: (1) the employer; (2) the employer’s insurance carrier; (3) a billing review service on behalf of the employer or the employer’s insurance carrier; or (4) a direct provider network that has contracted with the employer or the employer’s insurance carrier. Id. at § 22-3-3-5.2(b)(1); see also § 22-3-6-1(k)(2)(A) (defining pecuniary liability).
Even after this new reimbursement rate takes effect July 1, 2014, medical service providers, such as physicians, will continue to be reimbursed pursuant to the 80th percentile reimbursement rate that is already established by the Act. Based on the law, medical service provider is now defined as “a person or entity that provides services or products to an employee under IC 22-3-2 through IC 22-3-6.” Id. at § 22-3-6-1(i). The relevant portion of the Act reads:
This subdivision applies before July 1, 2014, to all medical service providers, and after June 30, 2014, to a medical service provider that is not a medical service facility. Payment of the charges in a defined community, equal to or less than the charges made by medical service providers at the eightieth percentile in the same community for like services or products.
Id. at § 22-3-3-5.2(a)(3); see also § 22-3-6-1(k)(1) (defining pecuniary liability).
Services Provided Outside Indiana
Because Indiana had no fee schedule and the statute did not contemplate medical services provided outside of the State of Indiana, it appeared that “usual and customary” was the only applicable standard available, if the claim or case was under Indiana’s jurisdiction.