DAR File No. 27899

Labor Commission, Industrial Accidents

R612-2-5

Regulation of Medical Practitioner Fees

NOTICE OF PROPOSED RULE

DAR File No.: 27899
Filed: 05/13/2005, 02:52
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment updates standards for determining fees for medical practitioners treating work-related injuries and illnesses. The amendment also increases the fees allowed for categories of medical care described as "medicine" and "restorative medicine."

Summary of the rule or change:

This amendment incorporates by reference the 2005 version of the "Resource Based Relative Value Scale" which is used in establishing fees for medical practitioners in workers' compensation cases. The amendment increases from $42 to $44 the unit value for medicine and restorative medicine services. The amendment also increase the relative values of four restorative medicine treatment codes. The amendment also provides a reference to the Labor Commission's web site.

State statutory or constitutional authorization for this rule:

Sections 34A-2-101 et seq., 34A-3-101 et seq., and 34A-1-104

National Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) "Resource-Based Relative Value Scale", 2005 edition, and the American Medical Association's CPT-4, 2005 edition.

Anticipated cost or savings to:

the state budget:

This amendment imposes no additional costs of administration. Regarding cost to the State in its capacity as an employer, the aggregate cost to all Utah employers is estimated at $2,000,000. This represents an increase of 1% in workers' compensation medical costs, which will be factored into workers' compensation insurance premiums over time.

local governments:

The aggregate cost of this amendment to all Utah employers is estimated at $2,000,000. This represents an increase of 1% in workers' compensation medical costs, which will be factored into workers' compensation insurance premiums over time.

other persons:

Health care providers providing "medical" and "restorative medical" services to injured workers will receive increased fees totaling $2,000,000. This represents an increase of 1% in workers' compensation medical costs, which will be factored into workers' compensation insurance premiums over time.

Compliance costs for affected persons:

Compliance costs are limited to possible minor increases in overall workers' compensation rates resulting from the increase in workers' compensation medical payments.

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

This small increase in payments to medical providers under the workers' compensation system is approximately 1% of current medical costs. This amount will be factored into future workers' compensation premiums, but is expected to have a negligible impact on businesses that purchase workers' compensation insurance. R. Lee Ellertson, Commissioner

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

Direct questions regarding this rule to:

Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@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:

07/01/2005

This rule may become effective on:

07/02/2005

Authorized by:

R Lee Ellertson, 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:

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 as required for the treatment of a work-related injury or illness.

2. Adopts and by this reference incorporates the National [Health Care Financing Administration's (HCFA)]Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) "Resource-Based Relative Value Scale" (RBRVS), 200[3]5 edition, as the method for calculating reimbursement and the American Medical Association's CPT-4, 200[3]5 edition, coding guidelines. 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. The CPT-4 coding guidelines and RBRVS are subject to the Utah Labor Commission's 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 [2, 2003]1, 2005:

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

Medicine $[42.00]44.00;

Pathology and Laboratory 150% of Utah's published Medicare carrier;

Radiology $53.00;

Restorative Medicine $[42.00]44.00, with Utah code 97001 and 97003 at a [0.8]1.5 relative value unit and Utah code 97002 and 97004 at a [0.5]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 Medical Fee Guidelines and Codes, as of [June 1, 2002]July 1, 2005. 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 www.laborcommission.utah.gov/indacc/indacc.htm.

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.

KEY: workers' compensation, fees, medical practitioner

[July 2, 2003]2005

Notice of Continuation May 28, 2003

34A-2-101 et seq.

34A-3-101 et seq.

34A-1-104

ADDITIONAL INFORMATION

PLEASE NOTE:

• Text to be deleted is struck through and surrounded by brackets (e.g., [example]). Text to be added is underlined (e.g., example). Some browsers may not depict some or any of these attributes on the screen or when the document is printed.
• Please see the DISCLAIMER regarding information available from state web pages.

For questions regarding the content or application of this rule, please contact Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.