The following questions pertain to the rules and regulations governing charges for medical services provided under the Idaho Workers’ Compensation Law IDAPA 17.01.01.404.
The Idaho Industrial Commission adopts the Resource-Based Relative Value Scale (RBRVS), published by the Centers for Medicare & Medicaid Services of the US Department of Health & Human Services, as the standard to be used for determining the acceptable charge for medical services provided by physicians.
Effective January 1, 2012, the Commission adopts the Medicare Severity ‑ Diagnosis Related Group (MS‑DRG) reimbursement method for inpatient services provided by hospitals other than critical access hospitals (CAH) or rehabilitation hospitals. The Ambulatory Payment Classification (APC) reimbursement method is adopted as the standard for hospital outpatient departments (HOPD) and Ambulatory Surgery Centers (ASC).
The standard reimbursement for medical services provided by Providers other than physicians, hospitals, or ASCs is the reasonable charge not to exceed the Provider’s “usual” charge and not to exceed the “customary” charge.
The FAQ is broken into five sections:
What is an acceptable charge?
An acceptable charge is the lower of the following: 1) the charge for medical services calculated in accordance with the fee schedule under IDAPA 17.01.01.803; 2) the charge billed by the provider; or, 3) the charge agreed to pursuant to a written contract. IDAPA 17.01.01.07.a.
For calculation of the acceptable charge for medical services provided by physicians, the conversion factors are to be multiplied by the facility or non‑facility total relative value unit (“RVU”) as determined by place of service found in the latest RBRVS, as amended, in effect on the first day of January of the current calendar year. IDAPA 17.01.01.803.02.
For calculation of the acceptable charge for inpatient hospital services, the base rate for hospital inpatient services is to be multiplied by the current MS-DRG weight for that service. Surgically implanted hardware may be allowed at the rate of actual cost plus fifty‑percent (50%), if the implant threshold criteria is met. IDAPA 17.01.01.803.03.b.
For calculation of the acceptable charge for outpatient hospital and ambulatory surgery center services, the applicable base rate is to be multiplied by the APC weight in effect on the first day of January of the current calendar year. IDAPA 17.01.01.803.03.c.
For critical access hospitals, the acceptable charge is 90% of the reasonable charge. IDAPA 17.01.01.803.03.a.
For non-critical access hospitals and ASCs, there are other payments that might be allowed in certain circumstances in addition to the amount allocated within the MS-DRG or APC payment. IDAPA 17.01.01.803.03.d.
For medicine provided by pharmacies, the acceptable charge is the average wholesale price (“AWP”) plus a dispensing fee for prescription medication, or the reasonable charge plus a dispensing fee for over-the-counter medication. IDAPA 17.01.01.803.04.
For historical medical fee schedules, click here.
What is a reasonable charge?
A reasonable charge does not exceed the provider’s usual charge and does not exceed the customary charge. IDAPA 17.01.01.010.07.c. Therefore, a reasonable charge is one that is both usual and customary.
What is a provider’s usual charge?
A usual charge is the most frequent charge made by an individual provider for a given medical service to non‑industrially injured patients. IDAPA 17.01.01.010.07.d.
NOTE: When Industrial Commission staff reviews a provider’s motion* to determine whether a provider’s charge is usual, the staff looks for evidence that the disputed charge did not exceed that charged by the provider to non-industrial patients for the same service. A non-industrial patient is one who is not claiming a work-related injury or illness.
*The filing of motions is discussed below.
What types of evidence should be sent to establish that the charge is “usual?”
Examples of evidence include copies of billing statements, explanations of benefits, fee schedules and/or affidavits from which the Commission can conclude that the charges are the same regardless of whether the injury or illness arose out of and in the course of the patient’s employment.
What is a customary charge?
A customary charge shall have an upper limit no higher than the 90th percentile, as determined by the Commission, of usual charges made by Idaho providers for a given medical service. IDAPA 17.01.01.010.07.b.
Is it necessary to submit evidence that the charge is “customary?”
Whenever possible, it is helpful to submit evidence that the charge falls within the 90th percentile of what Idaho providers bill for the same services. If such evidence is not available, the Commission may determine whether the disputed charge is customary based on a survey of Idaho provider charges or any other provider charge data available to the Commission.
Are CPT codes required for billing physician services? Are modifiers required?
A provider’s bill shall, whenever possible, describe the medical service provided using the American Medical Association’s appropriate Current Procedural Terminology (“CPT”) coding, including any applicable modifiers, for the year in which the service was performed, and using current International Classification of Diseases (“ICD”) diagnostic coding, as well. IDAPA 17.01.01.404.01 & 17.01.01.803.06(b)(i).
What are medical reports as referenced in the IDAPA rule?
Medical reports are records that have been generated because a patient has been treated. Medical Report “Means and includes without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions, and medication records.” IDAPA 17.01.01.010.31.
Does the medical report have to be sent at the same time as the bill for services? What happens if the report does not accompany the bill? Can payers demand to see an invoice before issuing payment?
If requested by the payer, the provider’s bill must be accompanied by the corresponding medical report. Where the bill is not accompanied by the requested report, the timelines requiring prompt payment and the issuance of Preliminary Objections/Requests for Clarification by the payer do not commence until the report and bill have both been received by the payer. IDAPA 17.01.01.803.06.b.iii.
A payer can request invoices for implantable hardware or durable medical equipment. However, apart from when the invoice is required to calculate the acceptable charge, the invoice is not considered a required medical report and generally a bill should not be denied on the basis that an invoice was not provided to support it. Nevertheless, providing the invoice to the payer may assist the provider in rebutting the payer’s argument that the charge is unreasonable. For implantable hardware items the invoice must be provided to payer, as it is necessary to calculate the acceptable charge under IDAPA 17.01.01.803.03.d.
What forms are required when filing a motion for Approval of Disputed charges? To whom should the motion be sent?
“Motions or responses by any party may be submitted in writing by hand delivery to the Boise Office at the Chinden Campus 11321 W. Chinden Blvd. (Bldg. #2), Boise, Idaho 83714, faxed to 208-334-2321, mailed via USPS to P.O. Box 83720, Boise, Idaho 83720-0041, or emailed to firstname.lastname@example.org. Email requests will be considered as an original document. Additional original documents are not required.
Required documents shall be served on parties by mail, fax, or personal delivery.” JRP 19(C).
If the dispute concerns a payer’s failure to comply with timelines, what types of documentation should be submitted with the motion?
The provider should submit evidence demonstrating that it complied with all applicable timelines and that the payer did not.
Additionally, it would also be a best practice for a provider’s motion to document how its charge comports with the applicable fee schedule rule. For example, if a usual and customary analysis applies to the charge (such as would be the case with durable medical equipment) the provider should, whenever possible, also document that their charge is both usual and customary. This is the best practice even if the only issue appears to be based on timeliness as the payer may raise the issue in its response and the Commission will look to any information relevant to or bearing upon the calculation of the acceptable charge under the rules, regardless of whether the issue was raised by a party.
What types of documentation must be submitted when the medical service in dispute is not CPT-coded, or is unusual/exceptional?
As with any other motion, the provider should submit evidence that the disputed charge is its usual charge for that service, or a similar service.
When a service is not CPT-coded, or is unusual/exceptional, reasonableness is determined based on all relevant evidence available. The provider should submit documentation relating to and/or supporting the reasonableness of its charge for the service, as well as an explanation as to why the service provided is unusual/exceptional.
Tips for Success in Medical Fee Disputes:
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 or a response to a motion. The Commission has also created a separate page to answer frequently asked questions.
Disclaimer: Please keep in mind these are best practices to facilitate a favorable outcome for you on your motion if you are the provider, or in defense of your handling of the bill or calculation of the acceptable charge if you are the payer. You need not be dissuaded from filing a motion or a response if you suspect that you missed a deadline or feel that you cannot provide adequate documentation. Document what you can and make your best argument.
- DO document in your motion or response:
- The date you sent or received the bill;
- The date you sent or received the Preliminary Objection or Request for Clarification;
- The date you sent or received the written Reply;
- The date you sent or received the Final Objection;
- The date and amount of any payments sent or received;
- Any other relevant actions taken in response to the above;
- A brief explanation of how you have satisfied each step of the required Procedures Preliminary to Dispute Resolution under IDAPA 17.01.01.803.06. The IDAPA rules can be downloaded from our Laws, Rules, Legislation and Policy Memos page here; and,
- If relevant, how you have calculated the acceptable charge and/ or what AMA or CMS coding guidelines you are relying on.
- DO file your motion or response timely.
- See Judicial Rule of Practice and Procedure (“JRP”) 19(E) for timelines regarding when the filing of a motion and/or response is timely. The JRP can be downloaded from our Laws, Rules, Legislation and Policy Memos page here.
- DO use the standard forms.
- The forms can be downloaded from our FAQ page here.
- DO include:
- Copies of all bills actually sent (indicating which portion of the bill is in dispute);
- The Preliminary Objection or Request for Clarification sent or received;
- The written Reply sent or received;
- The Final Objection sent or received; and,
- Any other relevant communications and/or correspondence between the parties.
- DO include a brief narrative description of the issues, actions taken, communications that occurred, or other relevant information that might bear on the calculation of the acceptable charge or support your position on the issue.
- DO understand that Commission staff are legal, not medical or coding, professionals, and that the dispute process is a legal, not medical, forum.
- DO include a Certificate of Service documenting that you sent a copy of your motion or response and all supporting documents to the other party, as required by JRP 19(C).
- If you complete service via facsimile, you must include the fax number on the Certificate of Service in addition to the name of the party served to adequately document proof of service. Although not required, it can also be helpful to include the facsimile transmission confirmation page that reflects a successful facsimile transmission.
- Remember, you can file your motion or response via email by sending it to email@example.com, but you must still serve the motion or response on the other party via facsimile, mail or personal delivery.
- DO NOT send in multiple copies of the same document. Ex.: If you are responding to a motion as a payer, it is generally not necessary to also send us a copy of the original motion and supporting documents that you received from the provider.
- DO NOT send irrelevant medical records or bills and expect the Commission staff to sort them out.
- Be specific and reference in your narrative explanation how or why each document is relevant and/or supports your position.
- If you cite to specific authorities, please include adequate details for Commission staff to be able to reference the source material (if you reference online materials, please include a link to the source page).
DO NOT hesitate to call Commission staff before you send in a motion or response to a motion if you have any questions. Please bear in mind that Commission staff will only be able to assist you with procedural matters. We cannot assist you in how to make your case.