Medical Information
Physicians in workers' compensation cases are defined in Idaho Code as "medical physicians and surgeons, ophthalmologists, otorhinolaryngologists, dentists, osteopaths, osteopathic physicians and surgeons, optometrists, podiatrists, chiropractic physicians, and members of any other healing profession licensed or authorized by the statutes of this state to practice such profession within the scope of their practice as defined by the statutes of this state and as authorized by their licenses."
This page is designed to provide basic information regarding billing and treatment in workers' compensation cases. It is by no means exhaustive. Contact the Idaho Industrial Commission for additional information.
HIPAA (top)
The Industrial Commission has issued a policy statement regarding HIPAA's application to workers' compensation and the Idaho Industrial Commission.
Change of Physician (top)
Under the Idaho workers' compensation system, the employer/surety may assign a medical provider to treat the injured worker. However, the worker may appeal that assignment to the Idaho Industrial Commission.
- Rules for Change of Physician appeals
- Change of Physician, Claimant Request Form
- Change of Physician, Employer/Insurer Response Form
Medical Billing (top)
Medical Fee Schedule
Payments for Physician Services
The Idaho Industrial Commission has adopted a new temporary rule governing payments for medical services under the Idaho Workers' Compensation Law. This rule is effectiveMay 8, 2009, and is applicable to all workers’ compensation medical services provided on or after May 8, 2009.
Relative Value Units
The Relative Value Units Files, released by the Centers for Medicare and Medicaid services published in November 2008, is available online.
Historical Medical Fee Schedules
- Medical services provided between 04/01/06* through 03/14/07
- Medical services provided between 03/15/07 through 04/01/08
- Medical services provided between 04/02/08 through 6-30-08
- Medical services provided between 07/01/08 through 05/07/09
- November 2007 RVU file, released by the Centers for Medicare and Medicaid services
*All medical services preceding 4-01-06 are subject to usual and customary charges.
Payments for Facilities
Idaho's fee schedule differentiates hospitals by the number of acute care beds. A large hospital is a facility with more than one hundred (100) acute care beds, while a small hospital is a facility with one hundred (100) acute care beds or less. The standard for determining the acceptable charge for hospitals and ASCs shall be:
- For large hospitals: Eighty-five percent (85%) of the appropriate inpatient charge.
- For small hospitals: Ninety percent (90%) of the appropriate inpatient charge.
- For ambulatory surgery centers (ASCs) and hospital outpatient charges: Eighty percent (80%) of the appropriate charge.
- Surgically implanted hardware shall be reimbursed at the rate of actual cost plus fifty percent (50%).
Questions regarding the medical fee schedule may be directed to Patti Vaughn, Medical Fee Schedule Analyst.
Coverage Verification
The Commission offers an online coverage verification service. Information regarding the name of the insurer and adjuster covering an employer can be obtained by email.
Balance Billing
Idaho is a zero-deductible state for workers' compensation medical charges. No portion of the unpaid medical bill is to be paid by the injured worker on claims accepted by the surety.
Medical Records
As noted in IDAPA 17.02.04.322.02, Providers shall submit written medical reports for each medical visit to the Payor. Payers and Providers may contract with one another to identify specific records that will be provided in support of billings. The Provider shall also submit the same written medical reports to the Claimant upon request. These reports shall be submitted within fourteen (14) days following each evaluation, examination and/or treatment. The first copy of any such reports shall be provided to the Payor and the Claimant or Claimant's Counsel at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports.
The first copy of any such reports shall be provided to the Payor and the Claimant at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports.
This means the medical provider must give one free copy to one of each of the following:
- Employer or insurance company
- Claimant (patient) or claimant’s attorney
- The Idaho Industrial Commission
Consultant Reports (top)
A medical fee schedule consultant from Ingenix presented highlights of their findings on physician charges in a public hearing held in Boise on October 15, 2007.
Informational sessions regarding facility reimbursement were held in May 2008. The sessions were presented by the medical fee consultant from Ingenix.
Dispute Resolution (top)
The Commission has prepared some items to help navigate the medical fee dispute process. Below are tips for filing a motion for approval of a disputed charge. The Commission has also created a separate page to answer frequently asked questions.
Medical Fee Dispute Do's and Don'ts:
- DO list in the motion:
- The date the bill was sent/received.
- The date the Preliminary Objection was sent/received.
- The date the Response was sent/received.
- The date the Final Objection was sent/received.
- DO check the deadlines before you send the motion.
- DO use the standard forms.
- DO itemize billings by CPT code.
- DO make sure you allege that the charges are your usual charges.
- DO provide copies of the:
- Bills (but indicate which part of the bill is in dispute)
- Preliminary Objection
- Response
- Final Objection.
- DO understand that Commission staff are legal, not medical, professionals, and that the dispute process is a legal, not medical, forum.
- DO send copies to the other parties.
- DO indicate the dates of the documents.
- DO organize your billing information before filing.
- DON’T send in multiple copies of the same item.
- DON’T forget to fully complete a certificate of service/mailing.
- DON’T hesitate to call Commission staff before you send in the motion if you have any questions.