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 four sections:
What is an acceptable charge?
An acceptable charge is the lower of the charge for medical services calculated in accordance with this rule or as billed by the Provider, or the charge agreed to pursuant to a written contract.
The conversion factors are to be applied to the fully‑implemented facility or non‑facility total relative value unit (RVU) as determined by place of service found in the latest RBRVS, as amended, that was published before December 31 of the previous calendar year. [See IDAPA 17.01.01.404].
Effective January 1, 2012:
The base rate for hospital inpatient services is to be applied to the current MS-DRG weight for that service. [See IDAPA 17.01.01.404].
The base rate for hospital outpatient and ASC services is to be applied to the APC weight in effect on the first day of January of the current calendar year. [See IDAPA 17.01.01.404].
For historical medical fee schedules, click here.
What is the acceptable charge for implanted hardware?
Physicians, critical access hospitals, and rehabilitation hospitals, are allowed the rate of actual cost plus fifty‑percent (50%) for surgically implantable hardware.
In addition to the amount allocated within the MS-DRG or APC payment, non-critical access hospitals and ASCs are allowed the rate of actual cost plus ten-percent (10%).
What is a reasonable charge?
A reasonable charge does not exceed the Provider’s “usual” charge and does not exceed the “customary” charge.
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.
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.
*A description of the term Motion is included in the following information.
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.
What are medical services? Are pharmaceutical drugs included as a medical service?
Medical services include medical, surgical, dental, or other attendance or treatment, nurse and hospital service, medicine, apparatus, appliance, prostheses, and related service, facility, equipment and supply. As a form of medicine, pharmaceutical drugs are considered a medical service for purposes of the Commission regulations.
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 modifiers, for the year in which the service was performed, and using current International Classification of Diseases (ICD) diagnostic coding, as well. [See IDAPA 17.01.01.404]
What are medical reports as referenced in the IDAPA rule?
Medical reports are records that have been generated because a patient has been treated. As defined under IDAPA 17.01.01.404, a “medical report” includes, without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions and medication records, et al.
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?
If requested by the Payor, 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 Payor do not commence until the report and bill have both been received by the Payor [See IDAPA 17.01.01.404].
With the exception of implantable hardware items, a Payor cannot make a blanket request for all invoices to support a given multi-item bill. However, if as part of the Dispute Resolution process a Payor can show that a given charge is on its face unreasonable, the Provider may then be required to produce the invoice to rebut Payor’s demonstration that the charge is unreasonable.
What forms are required when filing a Motion for Approval of Disputed charges? To whom should the Motion be sent?
All forms and supporting documentation must be sent to the Industrial Commission and served upon the Payor within the timelines established in the regulations. “Served upon the Payor” means delivered to the Payor. Two common examples include hand delivery and delivery by US Mail, postage prepaid.
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, their 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 or otherwise.
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 other Idaho providers. If such evidence is not available, the Commission may determine whether the disputed charge is “customary” based on a survey of Idaho Provider charges.
If the dispute concerns a Payor’s failure to comply with timelines, what types of documentation should be submitted with the Motion?
The Provider should submit evidence that it complied with all applicable timelines and that the Payor did not.
A Provider’s Motion should also contain evidence that the Provider’s charge is its “usual” charge, even if the only issue appears to be based on timeliness. Commission staff will determine if the charge submitted in the Motion is “customary” as well.
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.