Arkanas

November 10, 2011: Arkansas: Issues:
Hospital in-patient fee schedule

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

Medical Control

The employer has the right to choose the provider or providers for medical care but
notice of these choices must be given to employees. If the employee is not satisfied with
the initial provider, he/she may ask the employer/insurer to approve another provider.
The injured employee may also petition the Arkansas Workers' Compensation
Commission one (1) time only for a change of provider and the Commission determines
the second provider. The change may include a chiropractor, podiatrist or optometrist
when the employer/insurer is provided advance written notification. 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.

Out-of-State Providers

All services and requests for change-of-physician to out-of-state providers must be made
to providers who agree to abide by the AWCC medical Fee Schedule. Providers shall sign
an agreement stating they shall comply with AWCC Rule 30. Carriers/self insured
employers which are not contracted with a certified Managed Care Organization shall be
responsible for obtaining this agreement.

Almost every working Arkansan is protected by the Workers' Compensation
Law, but there are a few exceptions. Businesses where there are two or fewer
employees may not be covered. Railroad and maritime workers are covered by
federal laws. The Arkansas W orkers' Compensation Law does not apply to
employment of agricultural farm labor, domestic help, or employment by non-
profit, religious, charitable or relief organizations. Also exempt from the law are
personnel covered exclusively by federal law.

Workers' compensation covers accidental injuries which arise out of, and in the
course of employment, cause internal or external harm to the body, are caused
by a specific incident and are identifiable by time and place of occurrence. There
are three exceptions to the specific incident, and time and place requirement: (1)
rapid repetitive motion injuries, including carpal tunnel; (2) gradual on-set back
injuries; and (3) hearing loss. These three injuries are compensable only in those
cases in which the resultant condition is the "m ajor cause" of the need for
treatment and/or disability or death. Major cause is defined as more than 50% of
the cause. Mental injuries and heart attacks are addressed by specific statutory
provisions. A mental injury must be caused by a physical injury to the
employee's body, and disability benefits are limited to 26 weeks. However, the
physical injury requirement shall not apply to any victim of a crime of violence.
A heart attack is compensable only if an accident is the major cause of the
physical injury. The exertion of work which caused the heart attack must have
been extraordinary and unusual in comparison to the employee's regular
employment. Or, some unusual and unpredicted incident must have occurred
which was the major cause of the physical harm. The law also provides coverage
for occupational diseases which arise out of and are in the course of
employment. Ordinary diseases of life to which the general public is exposed are
not covered as a general rule.

The Arkansas W orkers' Compensation Law sets forth specific procedures
which must be followed to determine if a change of physician is appropriate. If
the employer or insurance carrier has not approved your change of physician
request, you may contact the Legal Advisor Division of the Workers'
Compensation Commission regarding the change of physician procedure. Failure
to follow the change of physician rules could result in denial of payment for
medical treatment from that physician. Change of Physician requests cannot be
approved over the telephone by the Legal Advisor Division.

Preauthorization

Preauthorization is required for all nonemergency hospitalizations, transfers between
facilities, and outpatient services expected to exceed $1,000.00 in billed charges for a
single date of service by a provider. A denial decision for payment for any type of health
care services and/or treatment resulting from a utilization review, as opposed to a
determination of whether such service or treatment is related to a compensable injury,
shall only be made by an Arkansas certified private review agent. The Arkansas
Department of Health Utilization Review certification number is required upon request.
See Arkansas Workers’ Compensation Hospital Inpatient Fee Schedule Part III for
procedures for requesting preauthorization. Upon emergency admission, notice must be
given to the carrier within 24 hours or for the next
business day.

II. PROCESS FOR RESOLVING DIFFERENCES BETWEEN CARRIER
AND PROVIDER

REGARDING BILL
A. Carrier’s dispute of a Bill
1. When a carrier adjusts and/or disputes a bill or portion thereof, the carrier
shall notify the provider within 30 days of the receipt of the bill of the specific reasons
for adjusting and/or disputing the bill or portion thereof, and shall notify the provider of
its right to provide additional information and to request reconsideration of the carrier’s
action.
2. If the provider sends a bill to a carrier and the carrier does not respond in 30
days, and if a provider sends a second bill and receives no response within 60 days from
the date the provider supplied the first bill, the provider may then file a request for
Administrative
Review with the Administrator of the Medical Cost Containment Division, with a copy
to thecarrier.
3. The carrier shall notify the employer, employee and the provider that the rules
prohibit a provider from billing an employee, employer, or carrier for any amount for
health care services provided for the treatment of a covered work-related injury or illness
when that amount is disputed by the carrier pursuant to its utilization review program,
or when the amount exceeds the maximum allowable payment established by the Fee
Schedule. The carrier shall
request the employee to notify the carrier if the provider so bills the employee, or
employer.
4. The carrier shall notify the Medical Cost Containment Division when a
provider attempts to balance bill or attempts to bill when a disputed exists between a
carrier and a provider regarding services.
a. A disk audit shall be conducted by the Medical Cost Containment Division on all
notices regarding balance billing.
b. The provider and carrier shall be notified of the results of the desk audit.
c. Providers found guilty of balance billing shall be counseled (1st offense) and
may be referred to the appropriate authority (2nd offense).
d. Providers found guilty of balance billing may ask for a review of the decision before
referral by the Medical Cost Containment Division to the appropriate authority.
B. Provider’s Request for Reconsideration of Bill
A provider may request reconsideration of its adjusted and/or disputed bill by a
carrier within 30 days of receipt of a notice of an adjusted and/or disputed bill or portion
thereof.
The provider’s request to the carrier for reconsideration of the adjusted and/or disputed
bill shall include a statement in detail of the reasons for disagreement with the carrier’s
adjustment and/or dispute of a bill or portion thereof.
C. Carrier’s Response to Provider’s Request for Reconsideration of Bill;
Provider’s Right to Appeal
1. Within 30 days of receipt of a provider’s request for reconsideration, the
carrier shall notify the provider of the actions taken and a detailed statement of the
reasons. The carrier’s notification shall include an explanation of the appeal process
provided under this
rule.
2. If a provider is in disagreement with the action taken by the carrier on its
request for reconsideration, the provider may file a request for Administrative Review
within 30 days from the date of receipt of a carrier’s denial of the provider’s request for
reconsideration,
and the provider shall supply a copy to the carrier.
3. If within 60 days of the provider’s request for reconsideration, the provider
does not receive payment for the adjusted and or disputed bill or portion thereof, or a
written detailed statement of the treasons for the actions taken by the carrier, then the
provider may make application for Administrative Review.
D. Disputes
1. Unresolved disputes between a carrier and provider due to conflicting
interpretation of Rule 30 and/or the Official Medical Fee Schedule may be appealed to,
and resolved by, the Administrator of the Cost Containment Division. A request for
Administrative
Review may be submitted to:
Administrator of the Cost Containment Division
Arkansas Workers’ Compensation Commission
P. O. Box 950
Little Rock, AR 72203-0950
2. Valid requests for Administrative Review do not require a particular form but must be
legible and contain copies of the following:
a. Copies of the original and resubmitted bills in dispute which include dates of
service, procedure codes, charges for ser vices rendered and any payment received, and
an explanation of unusual services or circumstances.
b. Copies of the specific reimbursement.
c. Supporting documentation and correspondence, if any.
d. Specific information regarding contact with the carriers.
e. A verified or declared written medical report signed by the physician.
f. A specific written request for Administrative Review.
3. The party requesting Administrative Review must send a copy of the request
and all documentation accompanying the request to the opposing party.
III. HEARINGS
A. Administrative Review Procedure
1. When the request for Administrative Review is received by the Administrator and it is
determined that the Commission has jurisdiction over the cause of action, all parties shall
be notified by certified mail return receipt requested. All parties shall have thirty (30)
days from the date of receipt of notification to submit further evidence, documentation,
or
clarifications to the Administrator. After thirty (30) days, a decision will be determined
by the Administrator and an order will be issued to the parties. Prior to this
determination, the Administrator may request all parties to attend a hearing on the
matter. The hearing shall be recorded verbatim. Failure to appear at such hearing may
result in dismissal of request for
Administrative Review.
2. Any party feeling aggrieved by the order of the Administrator shall have ten
(10) days from the date of notification to request a rehearing. A request for rehearing
shall be in writing and shall state the grounds upon which the moving party relies. Upon
a finding that the record is not complete or that error was made in the hearing process,
the Administrator may
order a rehearing. A rehearing shall follow the same procedure as Subsection