Medical Fee Schedule Issues
STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers’ Compensation
The Workers’ Compensation Division has received several complaints with regard to two issues. First, some payors are reimbursing board-eligible and board-certified orthopedic surgeons and neurosurgeons at the lower rate that is only applicable to non-board eligible or certified surgeons. Second, some payors are using the “lesser of” comparisons in the Medical Fee Schedule regulations on a line-by-line basis, rather than making comparisons on the total bill or amount due.
As to the first issue, the Division’s regulations located at 0800-2-18-.02(4)(a) require that board-eligible and board-certified orthopedic surgeons and neurosurgeons are to be reimbursed at 275% of Medicare rates. Non-board eligible orthopedic surgeons and neurosurgeons are to be reimbursed at general surgery rates, which are 200% of Medicare rates. Please note that you are free to contract for lower rates than those provided in our Medical Fee Schedule regulations. If, however, you are reimbursing board-eligible or certified orthopedic surgeons and neurosurgeons at the lower rate on the basis of anything other than a contracted rate or the surgeon’s usual charge, then this contravenes our policies. Since certification status is public record and payors should know the certification status of the doctors whom they choose to put on their panels, incorrectly reimbursing at the lower rate is unacceptable.
The second issue involves regulation 0800-2-18-.02(2)(b), which requires that reimbursement to providers must be the lesser of: (1) the provider’s usual charge; (2) the fee calculated pursuant to the Medical Fee Schedule; or (3) the MCO/PPO or any other contracted price. It is the policy of the Division that “This lesser of comparison must be done on the total bill or amount due, NOT a line-by-line comparison of items.” While the Division prefers not to penalize payors for reimbursing at inappropriate rates, it is an option that we will utilize if compliance is not obtained in the very near future (penalties can range up to $10,000 per violation).
Please be sure to consult the Medical Fee Schedule as well as other applicable regulations and statutes to ensure that you are in compliance. Thank you for your cooperation.
Workers’ Compensation Division
Posted: June 13th, 2008 under Announcements.
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