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Fee Schedule

Indiana will have a workers compensation medical fee schedule beginning 07/01/14. A billing review service must adhere to IC § 22-3-3-5.2.

House Enrolled Act 1320 established a fee schedule in Indiana of Medicare plus 100%, beginning July 1, 2014. For a detailed discussion of HEA 1320, see ICRB Circular 2013-04 and ICRB Circular 2013-05.
 
Prior to 2014, instead of a medical fee schedule, the Indiana workers compensation statute referred to geo-zip pricing limits referenced in IC § 22-3-6-1(j) “…equal to or less than the charges made by medical service providers at the 80th percentile in the same community for like services or products.” Also, IC § 22-3-6-1(h) says “’Community’ means a geographic service area based on zip code districts…”

A billing review service had to adhere to IC § 22-3-3-5.2.
 
Indiana had 8 geo zip districts. The threshold for payment was determined by what 80 of 100 doctors charged for a coded procedure/treatment (CPT code).
 

Services Provided Outside Indiana

Because Indiana had no fee schedule and the statute did not contemplate medical services provided outside of the State of Indiana, it appeared that "usual and customary" was the only applicable standard available, if the claim or case was under Indiana’s jurisdiction.

 
Studies

1. NCCI issued a report in January 2010 titled “Medicare and Workers Compensation Medical Cost Containment.”

The proportion of workers compensation medical costs that are subject to physician fee schedules is declining, with proportionally more billings by facilities.

2. Workers Compensation Research Institute (WCRI) issued a report in September 2009 titled "Workers’ Compensation Medical Cost Containment: A National Inventory"

The contains information about which medical cost containment strategies have been adopted by which states as of January 1, 2008.

 

The strategies include: medical fee schedules; regulation of hospital charges; medical and hospital bill review; choice of provider; treatment guidelines; utilization review/management; and managed care. Also included are the growing areas of pharmaceutical regulations; and urgent care and ambulatory surgical center fee schedules.

3. NCCI issued a report in December 2007 titled "Making Workers Compensation Medical Fee Schedules More Effective."

Excerpts: Fee schedules are the oldest and most widely used device to regulate WC medical payments. The primary finding is simply that fee schedules are effective at controlling WC medical costs. We also show that most schedules work well for primary care but not as well for specialty medicine.

Related Files

The material in this document has been prepared and shared for informational purposes only and should not be relied upon as legal advice on any particular situation.