Maine Workers’ Compensation Board Medical Fee Schedule Training

Statutory and Regulatory References Title 39-A § 205(4) Title 39-A § 206 Title 39-A § 208 Title 39-A § 209-A –Medical Fee Schedule: Board Rules and Regulations, Chapter 5 Title 39-A § 222 –Bureau of Insurance Rules, Chapter 530 Title 39-A § 306

Payment of bills for medical or health care services: Act § 205(4) When there is no ongoing dispute, if bills for medical or health care services are not paid within 30 days after the carrier has received notice of nonpayment by certified mail from the provider … or, if the bill was paid by the employee, from the employee …, $50 or the amount of the bill due, whichever is less, must be added and paid...Not more than $1,500 in total may be added.

Rights of Parties as to Medical and Other Services: Act § 206 An employee sustaining a personal injury arising out of and in the course of employment or disabled by occupational disease is entitled to reasonable and proper medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids, as needed, paid for by the employer.

Rights of Parties as to Medical and Other Services: Act § Employer selection. The employer initially has the right to select for the employee a health care provider authorized to practice as such under the laws of the State. 2. Employee selection. After 10 days from the inception of health care under subsection 1, the employee may select a different health care provider.

Certificate of Authorization: Act § 208 Authorization from the employee for release of medical information by health care providers to the employer is not required if the information pertains to treatment of an injury or disease that is claimed to be compensable under this Act.

Duties of health care providers: Act § 208 M-1 Form: –Except for claims for medical benefits only, within 5 business days from the completion of a medical examination –If ongoing medical treatment is being provided, every 30 days –Final report of treatment within 5 working days of the termination of treatment

M-1 Form: MFS Appendix I Must use the prescribed form. Except for the header information, the remainder of the M-1 form must be completed by the health care provider. This form must be distributed to the employee, employer and insurer (if known) directly. The M-1 form is not submitted to the board.

Medical Fee Schedule: Act § 209-A In order to ensure appropriate limitations on the cost of health care services while maintaining broad access for employees to health care providers in the State, the board shall adopt rules that establish a medical fee schedule setting the fees for medical and ancillary services and products rendered by individual health care practitioners and health care facilities.

Reimbursement Methodologies: Act § 209-A Resource Based Relative Value Scale –Measurement of the relative resource cost of providing individual physician services. Medicare Severity Diagnosis Related Group (MS-DRG) –Set of inpatient classes based on the principal diagnosis, secondary diagnosis, surgical procedures, age, sex and discharge status. –Fixed payment amount for an inpatient admission. Ambulatory Payment Classification (APC) –Groups together services, supplies, drugs and devices used in a particular outpatient procedure. –Fixed payment amount for a particular outpatient service.

Provisional Medical Payments: Act §222 Payment of benefits due a person under an insured disability plan or insured medical payments plan may not be delayed or refused because that person has filed a workers' compensation claim based on the same personal injury or disease. –Once a claim has been deemed to be work-related, payment is due within 10 days pursuant to the MFS.

Statute of Limitations: § Statute of limitations. Except as provided in this section, a petition brought under this Act is barred unless filed within 2 years after the date of injury or the date the employee's employer files a required first report of injury if required in section 303, whichever is later. 2. Payment of benefits. If an employer or insurer pays benefits under this Act, with or without prejudice, within the period provided in subsection 1, the period during which an employee or other interested party must file a petition is 6 years from the date of the most recent payment.

Statutory and Regulatory References There are no statutory or regulatory provisions regarding: NCCI/OCE Edits and Other Medicare Payment Policies and Reimbursement Rules Explanation of Benefits Appeals/Requests for Reconsideration

Patient Encounter Documentation M-1 Form Health Care Records Billing Reimbursement (pay, deny, other) Provider Reviews for Provider Review Appeal/Request for Reconsideration Provider Petition

Billing Procedures: Confirm Coverage/Billing Address Understand the difference between the employer/insurer and the claim administrator (may not be the same) Do not rely on internal lists Confirm coverage/address BEFORE sending the bill! The maine.gov/wcb website contains: A list of authorized self-insurers Access to coverage information submitted by carriers to NCCI

Confirm Coverage/Billing Address: Employer/Insurer Some employers are self-insured: –Individual Self-insurers – e.g. Bath Iron Works, Cianbro, Hannaford Brothers, State of Maine May administer its own claims May have a third party administer claims –Group self-insurers – e.g. Maine Automobile Dealers, Maine Healthcare Association, Maine Municipal Association, Maine School Management Association May administer its own claims May have a third party administer claims

Confirm Coverage/Billing Address: Employer/Insurer Some employers purchase workers’ compensation insurance policies from insurance carriers. An insurance carrier may: –administer its own claims – e.g. MEMIC –hire a third party to administer its claims – e.g. ACE, Old Republic –use a combination of both – e.g. AIG, Liberty, Travelers

Confirm Coverage/Billing Address: Third Party (TPA) Contractual arrangement with the insurer or self-insurer to administer claims Insurer who wrote the policy still ultimately responsible Generally chosen by the employer Examples – Broadspire, Constitution State Services, ESIS, Gallagher-Bassett, Helmsman, Sedgwick

Confirm Coverage/Billing Address: Other Third Parties Contractual arrangement with the insurer, self-insurer or TPA to provide managed care services such as bill review Insurer who wrote the policy or the self- insurer still ultimately responsible Examples - Genex, Corvel, MCMC, etc.

Notice of a Claim Lewis Wilson v. Central Maine Towing, Inc. and The Phoenix Insurance Co. –If a bill for medical services is received and accompanied by an M-1 and/or other medical information that identifies the time, place, cause and nature of the injury, the employer may be deemed to have knowledge of the injury. Bills for covered employers may not be returned to the provider because the employer has failed to report the claim.

Board Rules Chapter 5 aka Maine WC MFS Outlines billing procedures and reimbursement levels for health care providers who treat injured employees. Describes the dispute resolution process when there is a dispute regarding reimbursement and/or appropriateness of care. Sets standards for health care reporting.

Authorization: MFS Section 1.05 Nothing in the Act or these rules requires the authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39­-A M.R.S.A. § 206. An employer/insurer is not permitted to require pre-authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-­A M.R.S.A. § 206 as a condition of payment.

Billing Procedures: MFS Section 1.06 Bills must specify: (1) the billing entity’s tax identification number, (2) the license number, registration number, certificate number, or NPI of the health care provider, (3) the employer, (4) the date of injury/occurrence, (5) the date of service, (6) the work-related injury or disease treated, (7) the appropriate procedure code(s) for the work-related injury or disease treated, and (8) the charges for each procedure code.

Billing Procedures: MFS Section 1.06 Bills properly submitted on standardized claim forms prescribed by the Centers for Medicare & Medicaid are sufficient to comply with this requirement.  1500 instructions available at NUCC.org  UB instructions available at NUBC.org Uncoded bills may be returned for coding.

Billing Procedures: MFS Section 1.06 A bill must be accompanied by health care records to substantiate the services rendered. No authorization needed. Billing forms and accompanying health care records may NOT include diagnoses unrelated to the claimed injury.

Reimbursement: MFS Section 1.07(1) The injured employee is not liable for payment of any medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39­A M.R.S.A. § 206. Except as provided by 39­A M.R.S.A. §206(2)(B), health care providers may charge the patient directly only for the treatment of conditions that are unrelated to the compensable injury or disease. See 39­A M.R.S.A. §206(13).

Reimbursement: MFS Section 1.07(2) An employer/insurer is not liable for charges for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39­A M.R.S.A. § 206 in excess of the maximum allowable payment under this chapter.

Reimbursement: MFS Section 1.07(3) The employer/insurer must pay the health care provider's usual and customary charge or the maximum allowable payment under this chapter, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same health care provider have been controverted or denied.

Provider Review: Basic Reimbursement Concepts Usual and customary charge –Leanne Fernald v. Shaw’s Supermarkets, Inc. and William J. Babine v. Bath Iron Works –The charge on the price list for the medical service that is maintained by the provider

Provider Review: Basic Reimbursement Concepts Maximum Allowable Payment (MAP) –The sum of all fees for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids established by the Board pursuant to Chapter 5.

Reimbursement: MFS Section 1.07(4) Changes to bills are not allowed. When there is a dispute, the employer/insurer must pay the undisputed amounts, if any, and file a notice of controversy. A copy of the notice of controversy must be sent to the health care provider from whom the bill originated. A health care provider, employee or other interested party is entitled to file a petition.

Reimbursement: MFS Section 1.07(5) When there is a dispute whether a request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must file a notice of controversy. A copy of the notice of controversy must be sent to the originator of the request. A health care provider, employee, or other interested party is entitled to file a petition for determination of any dispute regarding the request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids.

Reimbursement: MFS Section 1.07(7) Nothing in this chapter precludes payment agreements. A written payment agreement directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available under this chapter. A written payment agreement between a health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available under this chapter only if the employer/insurer was a named beneficiary of the payment agreement at the time the health care provider signed the payment agreement.

Fees for Reports/Copies: MFS Section 1.08 Health care providers may charge for copies of the health care records required to accompany the bill. The charge is to be identified by billing CPT ® Code S9981 (units equal total number of pages). The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $

Fees for Reports/Copies: MFS Section 1.08 Health care providers must at the written request of the employer/insurer or the employer/insurer’s representative furnish copies of the health care records to the employer/insurer or the employer/insurer’s representative and to the employee’s representative (if none, to the employee) within 10 business days from receipt of a properly completed Form 220. –This form is HIPAA compliant. –This authorization pertains to information prior to and subsequent to the claimed workplace injury or disease that the employer/insurer contends is relevant to the determination of compensability and disability.

Fees for Reports/Copies: MFS Section 1.08 Health care providers must at the written request of the employee or the employee’s representative furnish copies of any written information (may include billing records) pertaining to a claimed workers’ compensation injury or disease regardless of whether the claimed injury or disease is denied by the employer/insurer. Copies must be furnished within 10 business days from receipt of the written request.

Medical Records: HIPAA If the employee or employee's representative wants copies of records prior to or subsequent to the claimed injury or illness, these records may be protected under federal privacy laws and the provider may require a completed HIPAA-compliant authorization before release of the records. Different laws may apply regarding the processing of any non-WC requests.

Fees for Reports/Copies: MFS Section 1.08 An itemized invoice must accompany the copies sent to the party requesting the records. The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $

Fees for Reports/Copies: MFS Section 1.08 The copying charge must be paid by the party requesting the records. Health care providers shall not require payment prior to responding to the request. Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.

Medical Information: MFS Section 1.11 Authorization from the employee for release of medical information by health care providers to the employee or the employee’s representative, employer or the employer’s representative, or insurer or insurer’s representative is not required if the information pertains to treatment of an injury or disease that is claimed to be compensable under this Act regardless of whether the claimed injury or disease is denied by the employer/insurer.

Medical Records: MFS Section 1.11 Nothing in the Act or these rules requires any personal or telephonic contact between any health care provider and a representative of the employer/insurer. Health care providers must complete the M-1 form in accordance with Title 39­A M.R.S.A. §208.

Billing Procedures – E & M Services Reminder: New v. Established Patient Billing for Evaluation & Management services requires the determination of patient status as new or established. According to the American Medical Association, a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. The determination is not based on the injury (new vs. existing).

Billing Procedures – Anesthesia: MFS Section 2.02 Health care providers must bill time units only. One time unit is allowed for each 15 minute time interval, or significant fraction thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, one time unit for each 10 minute time interval, or significant fraction thereof (5 minutes or more) is allowed after the first three hours. Documentation of actual anesthesia time is required, such as a copy of the anesthesia record.

Billing Procedures – Surgery: MFS Section 2.03 For surgical procedures that usually mandate a variety of attendant services, the reimbursement allowances are based on a global reimbursement concept. Global reimbursement covers the performance of the basic service and the normal range of care required before and after surgery. The normal range of post­surgical care is indicated under “FUD” in Appendix II.

Billing Procedures – Surgery: MFS Section 2.03 There are four exceptions to the global reimbursement policy that may warrant additional reimbursement for services provided before surgery. Additional charges and reimbursement may be warranted for additional services rendered to treat complications, exacerbation, recurrence, or other diseases and injuries. Under such circumstances, additional reimbursement may be requested. An incidental surgery will not be paid under the Workers' Compensation system.

Provider Review: Professional Services MAP using Section 2 and Appendix II. –Based on National Physician Fee Schedule Relative Value File and the Board’s base rates. –Lesser of logic applied line by line.

Provider Review: Inpatient Facility Fees MAP using Section 3 and Appendix III. –Based on Table 5.—List of Medicare Severity Diagnosis-Related Groups (MS- DRGS) and the Board’s base rates. –Lesser of logic applied at total claim level.

Provider Review: Inpatient Facility Fees continued Outliers – threshold is $75, plus the fee in Appendix III. –No need to request outlier payment. Implantables – hospitals may seek additional reimbursement for implantables over $10,000. –Must submit substantiating invoices. Invoices should be submitted contemporaneously with the bill. Professional Services – max fees as outlined in Appendix II.

Provider Review: Outpatient Facility Fees MAP using Section 4 and Appendix IV. –Based on Addendum B.-Final OPPS Payment by HCPCS Code and the Board’s base rates. –Lesser of logic applied at total claim level.

Provider Review: Outpatient Facility Fees continued Outliers – threshold is $2, per procedure code plus the fee in Appendix IV. –No need to request outlier payment. Implantables – facilities may seek additional reimbursement for implantables over $250. –Must submit substantiating invoices. Invoices should be submitted contemporaneously with the bill. Professional Services – max fees as outlined in Appendix II.

Provider Review: Claim Status Claim on File –ER/IR has 30 days to pay or deny. No claim on file, consider: –Billing the patient. The one that received the services is ultimately responsible for payment. –Sending notice of nonpayment via certified mail. –Contacting a Claims Resolution Specialist in one of the Board’s Regional Offices. –Contacting the Office of Medical/Rehabilitation Services. –Filing a Provider’s Petition for Payment of Medical and Related Services (WCB-190A).

Provider Review: Patient Financial Services Total Charges Less Total Amount Due = Adjustment Total Amount Due Less Total Amount Paid = Balance Due (if any)

Provider Review: Balance Due Partial denial filed –Automatically starts the Board’s dispute resolution process. Partial denial not filed, consider: –Filing an appeal /request for reconsideration with the payor. –Contacting the Office of Medical/Rehabilitation Services. –Contacting a Claims Resolution Specialist in one of the Board’s Regional Offices. –Filing a Provider’s Petition for Payment of Medical and Related Services (WCB-190A).

Dispute Resolution Three (3) Tiers –Claims Resolution Specialists (a.k.a.Troubleshooters) –Mediation –Hearing Five (5) Regional Offices –Augusta, Bangor, Caribou, Lewiston, Portland

Medicare Set Asides A WCMSA allocates a portion of a workers’ compensation settlement for all future work-injury-related medical expenses that are covered and otherwise reimbursable by Medicare.

Medicare Set Asides If a health care provider is treating an employee for a work injury and that employee has a Workers’ Compensation Medicare Set-Aside (WCMSA) based on the Maine Workers’ Compensation Medical Fee Schedule, the provider must bill the employee directly using the billing procedures outlined in Board Rules Chapter 5.

Medicare Set Asides Employees with a WCMSA based on the Maine Workers’ Compensation Fee Schedule are required to pay for treatment related to the work injury pursuant to the Maine Workers’ Compensation Medical Fee Schedule.

Medicare Set Asides Health care providers may wish to establish a separate financial class for employees with a WCMSA to facilitate the billing process. If a health care provider mistakenly bills Medicare or other insurer for treatment related to the work injury, the provider is responsible for refunding any payments received for that treatment.

Recovery of Overpayments Workers’ Compensation Board Decision No.96-0:Donald C. Pritchard, Jr. v. S.D. Warren Company and Sedgwick James of Northern New England The present Act provides this employer with no mechanism to recover what the employer regards as an overpayment of compensation.

Messages from Executive Director Board of Directors –Meeting agendas –Meeting minutes Proposed Rules List serves –Notice of Rulemaking, Board agendas/minutes –MRS News

Medical/Rehab Services –Medical Fee Schedule Annual updates effective Oct. 1 and Jan. 1 Periodic updates every 3 years FAQ Training materials

Featured Links –Insurance Coverage Verification List of Authorized Self-Insured Employers Access to Coverage Information for Insured Employers –Bureau of Insurance Insurance Company License and Contact Information – ALMSQuery/Welcome.aspx

Board Resources Abuse Investigation Unit – uninsured employers Audit Division – insurers, self-insurers and third party administrators non- compliance Coverage – insured employers Claims Resolution Specialists – Claim on file, Claim Administrators, NOCs

Board Resources Office of Medical/Rehabilitation Services – a copy of the bill along with the corresponding medical records and any correspondence from the claim administrator to: