Alabama Workers com

ALABAMA WORKERS COMPENSATION
COMPREHENSIVE PUBLICATIONS AND INFORMATION
FOR INDUSTRIAL INJURIES

Fee Schedule for Hospitals based on per diem with stop lost

480-5-5-.37 Out-of-State Medical Providers

(1) Occasionally an employee, whose injury falls under Alabama’s
jurisdiction,
may require treatment by a medical provider in another state. Alabama’s
fee schedules are developed under the premise that treatment will be
provided in this state. The hospital and ambulatory surgery fee schedules
are unique to that particular Alabama facility. Other Alabama medical
providers’ reimbursement schedules are derived from the most common
payer of health care services in this state.

(2) Code of Alabama, 1975, § 25-5-77 limits the employer’s liability to
the prevailing rate or maximum schedule of fees. Prevailing is defined in
Code of Alabama, 1975, § 25-5-1(15) and Department of Industrial
Relations Administrative Code, Rule 480-5-5-.02(61). If another state has
a workers’ compensation fee schedule for that provider type, that
schedule constitutes the prevailing rate for treatment of a workers’
compensation injury.

(3) For any injury under Alabama’s jurisdiction, the out-of-state medical
provider is paid:

(a) According to that state’s workers’ compensation fee schedule for that
provider;
(b) According to a mutually negotiated payment rate pursuant to Code of
Alabama, 1975, § 25-5-314; or
(c) According to the Alabama workers’ compensation fee schedule for
nonfacility
medical providers.
Author: Workers' Compensation DivisionStatutory Authority: Code of
Alabama, 1975, §25-5-77History: Effective March 21, 2011

W ork Comp Forms and related Documents

October 01, 2011: fee schedule

WORKERS' COMPENSATION FEE SCHEDULES
Fee Schedules for Doctors, Hospitals, Physicians’ Fee Schedule Codes,
In Office Surgery, etc.

Code of Alabama , 1975, Sections 25-5-290, 25-5-291, 25-5-292

Hospital Fee Schedule 2011

All Fee Schedules

Medical Control The employer has the right to direct an injured
employee to the initial physician for non-emergency medical
care. If the injured employee is dissatisfied with the initial
treating physician selected by the employer and further
treatment is necessary, the employee shall be entitled to select a
second physician from a panel or list of four (4) physicians
selected by the employer. The employee may select his/her own
pharmacy or select a pharmacy from the Express Scripts
pharmacy network. Emergency medical care does not require
preapproval and should be secured at the nearest location.

Disputed Medical Bills

If a claim for medical services rendered is disputed, notify the provider
that the claim is in dispute and advise them of the nature of the dispute.
This is crucial because medical providers can file a formal complaint with
the Director of Industrial Relations. §25-5-77(i) states, “Any party,
including a health care provider, is entitled to a review by an ombudsman
of medical services provided or for which authorization of payment is
sought if any party or health care provider has any of the following:
1. Been denied payment or had the charge reduced for medical services
rendered.
2. Been denied authorization for payment of services requested or
performed when authorization is required.
3. Been ordered by the Director to refund payments received for the
provision of medical services.
4. A party to a medical dispute that remains unresolved after a review of
medical services as provided by this section may petition the court for
relief.
5. In any review under this subsection of medical services provided by a
physician, any party to a dispute may request the ombudsman consult
with an independent medical expert from a list of at least three names
provided by the Workers’ compensation Medical Services Board in a
medical speciality appropriate to the issues raised in the dispute and shall
secure a written opinion from the independent medical expert. In
rendering a decision or recommendation, the ombudsman shall give full
consideration to the opinion of the independent medical expert, but shall
not be bound by that opinion.

Code of Alabama, 1975 §25-5-77(i) provides that "Any party, including a
health care provider, is entitled to review by an ombudsman of medical
services that are provided or for which authorization of payment is
sought..." To initiate this process the party may contact the Workers'
Compensation Division, Medical Section at (800) 528-5166. A member
of this section may discuss the dispute with you and perhaps resolve
concerns over the phone. However, the majority of the disputes will
require written communications between the Division and the involved
parties. The following documentation may be required for processing of
any dispute:
1.        The name, address, and phone numbers of the parties involved in
the dispute;
2.        A written narrative of the dispute;
3.        Copies of all medical bills (claim forms) and supporting
documentation; and/or
4.        Documentation of oral communications and copies of written
communications between parties.

MEDICAL DISPUTES - contact an employee of the Medical
(Mediations) section for additional information.

Pursuant to the Code of Alabama, 1975, §25-5-77(i)(5) we offer medical
dispute resolution. Please contact Sally Thames prior to submission of
the disputed claim. Once we receive an opinion from one of our
independent medical experts on the disputed issue or issues, we will
prepare a non-binding recommendation in writing.
Employees may request a medical mediation through this Division, or the
employee or his attorney may petition the court. The employer/carrier
may act on our recommendation or petition the court.

A medical mediation is handled the same as our compensation mediations,
except the issues to be mediated are medical issues and not settlement of
compensation. Contact Sally Thames for scheduling. If the parties agree
to a resolution of the medical issues in question, the parties shall sign a
binding mediation agreement.

A definition of Utilization Management, Utilization Review, and
Bill Screening follows:

Utilization Management is a comprehensive set of integrated components
including: pre-certification review, admission review, continued stay
review, retrospective review, discharge planning, bill screening and
individual medical case management as required.
Utilization Review is the determination of medical necessity for medical
and surgical in-hospital, outpatient, and alternative setting treatments for
acute and rehabilitation care. It includes pre-certification for elective
treatments. Concurrent review and, if necessary, retrospective review are
required for emergency cases.

Bill Screening is the evaluation and adjudication of provider bills for
appropriateness of reimbursement relative to medical necessity and
prevailing rates of reimbursement, duplicate charges, unbundling of
charges, relativeness of services to injury or illness, necessity of assistant
surgeons, adjudication of multiple procedures, number of modalities,
global procedures, and any other prevailing adjudication issues that may
apply.

In accordance with Code of Alabama, 1975, Section 25-5-293(k), the
Department of Industrial Relations has filed for adoption Alabama
Department of Industrial Relations Administrative Code Rules 480-5-5-.
01 through .35, Utilization Management and Bill Screening. The initial
effective date of these rules was September 12, 1996

Medical provider reimbursement Code of Alabama, 1975, §25-5-
77(h) & DIR Administrative Code 480-5-5-.04 Twenty-five (25)
working days from the date of receipt.

Medical provider submit a bill DIR Administrative Code 480-5-5-.33 -
One year from date of service.
Medical provider bill a workers’ compensation claimant for medical
services Code of Alabama, 1975 §§25-5-77(g) & 25-5-293 (g) - Not if the
treatment was authorized; however, the employer is not liable for medial
or surgical treatment obtained by the employee without justification or
notice to the employer.

Statute of Limitation of a workers’ compensation claim Two
years from the date of injury or two years from the date of last
compensation payment.

COLLECTION GUIDEBOOK
COMING 2012

January 24, 2012: Alabama News:
Employees of Michelin North America,
Inc., located in Opelika, Alabama who were
engaged in the production of passenger and
light truck radial tires may be eligible for
benefits under the federal Trade
Adjustment Assistance Act of 2011.

January 12, 2012: Alabama News: The U.
S. Department of Labor found that the
workers may have become unemployed as
a result of increased imports,

January 09, 2012: Alabama Issues:
OVERVIEW OF MEDIATION

December 19, 2011: Alabama News:
November unemployment rate experienced
another significant drop,

November 10, 2011:Alabama: Issues:
Code of Alabama 480-5-5-.37 Out-of-
State Medical Providers (1) Occasionally
an employee, whose injury falls under
Alabama’s jurisdiction, may require
treatment by a medical provider in another
state.

November 04, 2011: Alabama: News:
DIR News Release- Employees of Finish
Line Hosiery May be Eligible for
Additional Benefits - 11/4/2011

DIR News Release- Employees of
WestPoint Home May be Eligible for
Additional Benefits - 11/4/2011

October 07, 2011: W ork Comp Forms
and related Documents

October 01, 2011: fee schedule
WORKERS' COMPENSATION FEE
SCHEDULES
Fee Schedules for Doctors, Hospitals,
Physicians’ Fee Schedule Codes, In Office
Surgery, etc.