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.
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)
Update on Adoption of ICD-10 (NEW-10/1/15)
Effective October 1, 2015, all covered entities under the Health Insurance Portability Accountability Act (HIPAA) are required to bill with the ICD‑10 diagnostic coding set. Further information regarding ICD-10 may be obtained from the Centers for Medicare & Medicaid Services, or by contacting Patti Vaughn at the Industrial Commission, (208) 334-6084.
MEDICAL FEES (NEW-7/01/16)
Workers’ Compensation medical fees are governed by IDAPA 17.02.09.
Effective July 1, 2016, the Commission adopts changes that include:
- Clarification on how outpatient hospital procedures are to be paid in the presence or absence of Comprehensive Ambulatory Payment Classification (C-APC) codes including status indicator J1.
- The coding guidelines published by Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are adopted as a standard reference for facility charges unless a specific exception appears in the IDAPA rule.
- The standard for reimbursement of rehabilitation hospitals is changed to the same as other non-Critical Access Hospitals (CAH).
Please contact Patti Vaughn for further information at (208) 334-6084.
PAYMENT CALCULATION RESOURCES
Hospital Inpatient: MS-DRG
Table 5: List of FY17 MS-DRGs, Relative Weights (Effective October 1, 2016)
Table 5: List of FY16 MS-DRGs, Relative Weights (Effective October 1, 2015)
Hospital Outpatient & Ambulatory Surgery Centers (ASC)
- Medical services provided between 7/01/15 through 6/30/16
- Medical services provided between 01/01/15 through 06/30/15
- Medical services provided between 3/20/14 through 12/31/14
- Medical services provided between 07/01/13 through 03/19/14
- Medical services provided between 07/01/12 through 06/30/13
- Medical services provided between 04/07/11 through 06/30/12
- Facility services provided between 04/07/11 through 12/31/11
- Medical services provided between 03/29/10 through 04/06/11
- Medical services provided between 05/08/09 through 03/28/10
- Medical services provided between 07/01/08 through 05/07/09
- Medical services provided between 04/02/08 through 06/30/08
- Medical services provided between 03/15/07 through 04/01/08
- Medical services provided between 04/01/06* through 03/14/07
*All medical services preceding 4-01-06 are subject to usual and customary charges.
Questions regarding the medical fee schedule may be directed to Patti Vaughn, Medical Fee Schedule Analyst.
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.
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
Medical Data Reports (top)
Dispute Resolution (top)
Change to Application of 30% Penalty In Medical Fee Disputes
For all Motions filed on or after October 1, 2014, unless the payer demonstrates, by timely response to the provider’s Motion, that the payer’s previous payment is adequate, the penalty will now be applied to the underpayment owed at the time the Motion was filed. Payments issued after the filing of the Motion may be deducted from the ordered amount, but will not reduce the penalty. For more information, click here.
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.
- 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 provide copies of the
- Bills (but indicate which part of the bill is in dispute)
- Preliminary Objection
- 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.
- DON’T send in multiple copies of the same item.
- DON’T send a bunch of medical records or billing items and expect the Commission staff to sort them out.
- 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.