Q. What is The Maryland Workers' Compensation Medical Fee Guide
Gale Reikenis, RN, Chesapeake Employers Health Services Supervisor
Fee schedules for workers’ compensation are mandated in most states for the purpose of cost containment or standardization of payment to ensure access to medical care for injured workers.
Medical treatments and services provided to the injured worker as a result of their compensable injury are covered by the workers’ compensation carrier. The bills and reports are submitted by the medical provider directly to Chesapeake Employers, with standardized information on a CMS-1500 medical bill form. Information must include the diagnosis, procedure codes (commonly called CPT or Current Procedure Terminology codes), tax id of the provider, plus legible records.
TIP – make sure provider is given the Chesapeake Employers claim number so they submit it on the bill.
How does Chesapeake Employers or any other workers’ compensation
carrier know how much to pay for these medical services? The MD Workers’ Compensation Commission has an established Fee Guide, which documents the maximum allowance for each procedure code submitted by a provider. There are over 7,000 CPT codes that specifically describe the procedure(s) performed by the medical provider. Whether the code is for an office visit, physical therapy or a surgery, the maximum allowance is listed on the WCC website: http://www.wcc.state.md.us/
For example, a physician may charge $150 for CPT code 99214, an office visit code for an established patient, but the reimbursement set by the Fee Guide allows a maximum of $117.89 if the patient was seen in the doctor’s private office, or a maximum of $88.73 if the patient was seen in a clinic setting.
TIP – Submit all the medical bills for your injured worker to your compensation carrier, but if you chose to pay your employee’s bills, do not pay more than the Fee Schedule allowance!
Other services that are regulated by the WCC are Ambulatory Surgical Center and anesthesia services.
Additional rules apply to the reimbursements; one common example being the ‘multiple procedure rule’. If several codes are billed for a surgery for one date of service, the primary procedure is reimbursed at 100%, but the other procedures are reimbursed at 50%.
TIP - The FEE Guide is updated yearly, so the reimbursement depends on the date of service.
Though the allowance for provider codes is set by the MD WCC Fee Guide, other services are not, and must be determined by the insurance carrier based on standards or usual and customary services involving similar work. For example, the MD WCC Fee Guide does not provide allowances for prescriptions, dental fees, supplies or equipment. Also, in the state of Maryland, the HSCRC (Health Services Cost Review Commission) regulates hospital charges, not the WCC.
So if an employee breaks his ankle on the job, the emergency room physician, radiologist and orthopedist would all be reimbursed following the MD Workers’ Compensation Fee Schedule, but the hospital charge would be paid under HSCRC guidelines.
Tip: A medical provider cannot bill the injured worker for the difference between what the workers’ compensation carrier paid them and what the provider charged. This is called balance-billing. Any disputes would be resolved between the provider and the insurer, or by the WCC if needed.