The State of the States

Regulatory Review

Key workers' comp regulatory developments from across the country.
By: | February 27, 2014


Physician fee schedule: The Division of Workers’ Compensation adjusted the resource based relative value scale-based physician services and non-physician practitioner services section of the official medical fee schedule to conform to changes in the 2014 Medicare payment system. The update included adoption of the 2014 relative value units, the 2014 current procedural terminology codes, and updated conversion factors. The changes went into effect for services rendered on or after Jan. 1. More information can be found here.


Maximum workers’ compensation rate: The Department of Financial Services issued an informational bulletin regarding the maximum workers’ compensation rate. The maximum weekly compensation rate is $827. The rate went into effect on Jan. 1. Those with questions should contact Ryan Gagne at the Division of Workers’ Compensation at (850) 413-1771. For a copy of the bulletin, click here.

Health care provider reimbursement manual: The Division of Workers’ Compensation announced that a public meeting was schedule on Jan. 21 to facilitate the three-member panel’s consideration of the adoption of the 2014 health care provider reimbursement manual, which proposed the incorporation of a new fee schedule and modified language regarding dispensed medications. The panel also considered adopting the ambulatory surgical center schedule of rates. The panel also received the division’s annual report on the resolution of health care provider medical reimbursement disputes. Click here for more information.

New York

Uninsured Employers’ Fund: The Workers’ Compensation Board issued a bulletin regarding a change in the administration of established uninsured employers’ fund claims. Management of established claims will be transitioned to the Triad Group LLC effective Jan. 13. Workers with uninsured employers’ fund claims and all parties of interest, including health care providers and legal representatives will receive written notice of the change in claim administrator. For medical and transportation reimbursement requests after Jan. 13, the form for reimbursement must be sent to Triad for processing with a copy to the board. For medical services provided on or after Jan. 13, in established cases only, health care providers should send new medical reports, bills, and authorization requests to Triad, and a copy to the board. Those with questions regarding transitioned uninsured employers’ fund claims should send an email to cr[email protected]. A copy of the bulletin can be found on the WCB website.

Inpatient hospital care: The Department of Health provided the Workers’ Compensation Board with reimbursement rates for inpatient hospital care with discharge dates of Jan. 1, 2013 through Dec. 31, 2013. The new rates include medically managed detoxification and medically supervised inpatient withdrawal reimbursement rates. These rates reflect the detox rate reform provisions. The new rates also include inpatient hospital care reimbursement rates. These rates were determined using the Medicaid inpatient methodology. For more information, click here.


Self-insured rules: The Bureau of Workers’ Compensation proposed amendments to rules regarding self-insuring employers. A new rule would establish criteria for a waiver of self-insured requirements. The rules also would require the administrator to establish provisions for waiver of the requirement that self-insured applicants have 500 employees in the state and that applicants operate in the state for a minimum of two years. Existing language is proposed to be eliminated indicating that the cost of a commercial credit reporting bureau service to be used by the bureau to assist in the evaluation of an applicant’s financial strength must be paid by the applicant.For more information, visit the Bureau’s website.


Conversion factors: The Department of Labor and industries issued a preproposal statement of inquiry regarding rules describing elements used in the process of updating the maximum allowable payments for most professional health care services. The proposed rule changes update the conversion factors used by the department for calculating reimbursement rates for most professional health care and anesthesia services. The conversion factors will be updates to correspond to changes in the medical procedure codes, the relative value units, and anesthesia base units. Cost-of-living increases may be incorporated into the changes in the conversion factors. The rules also update the maximum daily reimbursement level for physical and occupational therapy services so the department may give cost-of-living increases to affected providers.  Comments should be submitted to [email protected]. For more information, click here.


Right of appeal for MSP determination: The Centers for Medicare and Medicaid Services proposed a rule implementing provisions of the Strengthening Medicare and Repaying Taxpayers Act. The SMART Act requires a right of appeal and appeal process for liability insurance, no-fault insurance, and workers’ compensation laws or plans when Medicare pursues a Medicare secondary payer recovery claim directly from the liability insurance, no-fault insurance, or workers’ compensation law or plan.

The proposed rule defines “applicable plan” as liability insurance, no-fault insurance, or a workers’ compensation law or plan. The applicable plan is a party to initial determinations, redeterminations, reconsiderations, hearings, reviews, and appeals. The rules also provide the applicable plan with parallel rights to a beneficiary’s rights or a provider or supplier’s rights regarding the duration of an appointment of representation with respect to an MSP recovery claim. A determination that Medicare has a recovery claim where Medicare is pursuing recovery directly from an applicable plan is an initial determination with respect to the existence of the MSP recovery claim. Comments will be accepted until Feb. 25. For more information, visit

Christina Lumbreras is a Legal Editor for Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]

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