| Idaho WORKERS COMPENSATION COLLECTION PUBLICATIONS AND INFORMATION FOR MEDICAL PROVIDERS |
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- Payments for Facilities
Idaho's fee schedule differentiates hospitals by the number of acute care beds. A large hospital
is a facility with more than one hundred (100) acute care beds, while a small hospital is a
facility with one hundred (100) acute care beds or less. The standard for determining the
acceptable charge for hospitals and ASCs shall be:
For large hospitals: Eighty-five percent (85%) of the appropriate inpatient charge.
For small hospitals: Ninety percent (90%) of the appropriate inpatient charge.
For ambulatory surgery centers (ASCs) and hospital outpatient charges: Eighty percent (80%)
of the appropriate charge.
Surgically implanted hardware shall be reimbursed at the rate of actual cost plus fifty percent
(50%).
- Medical Control
The employer/insurer may designate the initial treating provider or provider network as long as
it is disclosed at the time of hire and applied uniformly. Otherwise, the injured employee may
obtain initial medical treatment from a medical provider of his/her choice. The injured employee
may change to a new medical provider one time, but must notify the employer/insurer before
making the change. Subsequent changes in medical provider require approval from the
employer/insurance carrier before the change. The treating provider may refer the injured
employee to specialist(s) with the approval of the employer/insurer. 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.
- Tips for Success in Medical Fee Disputes:
a. The date the bill was sent/received.
b. The date the Preliminary Objection was sent/received.
c. The date the Response was sent/received.
d. The date the Final Objection was sent/received.
2. DO check the deadlines before you send the motion.
3. DO use the standard forms.
4. DO itemize billings by CPT code.
5. DO provide copies of the
a. Bills (but indicate which part of the bill is in dispute)
b. Preliminary Objection
c. Response
d. Final Objection
6. DO understand that Commission staff are legal, not medical, professionals, and that the
dispute process is a legal, not medical, forum.
7. DO send copies to the other parties.
8. DO indicate the dates of the documents.
9. DON’T send in multiple copies of the same item.
10. DON’T send a bunch of medical records or billing items and expect the Commission
staff to sort them out.
11. DON’T forget to fully complete a certificate of service/mailing.
12. DON’T hesitate to call Commission staff before you send in the motion if you have
any questions.
The Idaho Industrial Commission adopts the Resource-Based Relative Value Scale (RBRVS),
published by the Centers for Medicare & Medicaid Services of the US Department of Health &
Human Services, as the standard to be used for determining the acceptable charge for medical
services provided by physicians.
Effective January 1, 2012, the Commission adopts the Medicare Severity Diagnosis Related
Group (MS DRG) reimbursement method for inpatient services provided by hospitals other
than critical access hospitals (CAH) or rehabilitation hospitals. The Ambulatory Payment
Classification (APC) reimbursement method is adopted as the standard for hospital outpatient
departments (HOPD) and Ambulatory Surgery Centers (ASC).
The standard reimbursement for medical services provided by Providers other than physicians,
hospitals, or ASCs is the reasonable charge not to exceed the Provider’s “usual” charge and not
to exceed the “customary” charge.
An acceptable charge is the lower of the charge for medical services calculated in accordance
with this rule or as billed by the Provider, or the charge agreed to pursuant to a written contract.
The conversion factors are to be applied to the fully implemented facility or non facility total
relative value unit (RVU) as determined by place of service found in the latest RBRVS, as
amended, that was published before December 31 of the previous calendar year. [See IDAPA
17.02.09.031.03].
Effective January 1, 2012:
The base rate for hospital inpatient services is to be applied to the current MS-DRG weight for
that service. [See IDAPA 17.02.09.032.02(b)].
The base rate for hospital outpatient and ASC services is to be applied to the APC weight in
effect on the first day of January of the current calendar year. [See IDAPA 17.02.09.032.02(c)].
For historical medical fee schedules, click here.
Physicians, critical access hospitals, and rehabilitation hospitals, are allowed the rate of actual
cost plus fifty percent (50%) for surgically implantable hardware.
In addition to the amount allocated within the MS-DRG or APC payment, non-critical access
hospitals and ASCs are allowed the rate of actual cost plus ten-percent (10%).
A reasonable charge does not exceed the Provider’s “usual”charge and does not exceed the
“customary” charge.
A usual charge is the most frequent charge made by an individual Provider for a given medical
service to non industrially injured patients.
NOTE: When Industrial Commission staff reviews a Provider’s Motion* to determine whether
a Provider’s charge is “usual,” the staff looks for evidence that the disputed charge did not
exceed that charged by the Provider to non-industrial patients for the same service. A “non-
industrial patient” is one who is not claiming a work-related injury or illness.
*A description of the term Motion is included in the following information.
A customary charge shall have an upper limit no higher than the 90th percentile, as determined
by the Commission, of usual charges made by Idaho Providers for a given medical service.
Medical services include medical, surgical, dental, or other attendance or treatment, nurse and
hospital service, medicine, apparatus, appliance, prostheses, and related service, facility,
equipment and supply. As a form of medicine, pharmaceutical drugs are considered a medical
service for purposes of the Commission regulations.
A Provider’s bill shall, whenever possible, describe the Medical Service provided using the
American Medical Association’s appropriate Current Procedural Terminology (CPT) coding,
including modifiers, for the year in which the service was performed, and using current
International Classification of Diseases (ICD) diagnostic coding, as well. [See IDAPA
17.02.09.034.03(a).]
Medical reports are records that have been generated because a patient has been treated. As
defined under IDAPA 17.02.04.322.01(f), a “medical report” includes, without limitation, all
bills, chart notes, surgical records, testing results, treatment records, hospital records,
prescriptions and medication records, et al.
If requested by the Payor, the Provider’s bill must be accompanied by the corresponding
medical report.
Where the bill is not accompanied by the requested report, the timelines requiring prompt
payment and the issuance of Preliminary Objections/Requests for Clarification by the Payor do
not commence until the report and bill have both been received by the Payor [See IDAPA
17.02.09.034.03(c)].
With the exception of implantable hardware items, a Payor cannot make a blanket request for
all invoices to support a given multi-item bill. However, if as part of the Dispute Resolution
process a Payor can show that a given charge is on its face unreasonable, the Provider may then
be required to produce the invoice to rebut Payor’s demonstration that the charge is
unreasonable.
The Payor can request from the Provider additional information, such as invoices, that it
requires for review of the Provider’s bill. However, the Payor must make its request within
thirty (30) days from the date it receives the Provider’s bill [See IDAPA 17.02.09.034.06(b)].
If the Provider fails to timely reply to the Payor’s request, the period in which the Payor must
pay or issue a Final Objection does not begin until the Provider’s reply is received [See IDAPA
17.02.09.034.07(c)].
A Provider’s Motion must be filed on the forms provided in the Commission’s Judicial Rule.
These forms include the Motion, Certificate of Mailing, and Appendix A.
All forms and supporting documentation must be sent to the Industrial Commission and served
upon the Payor within the timelines established in the regulations. “Served upon the Payor”
means delivered to the Payor. Two common examples include hand delivery and delivery by
US Mail, postage prepaid.
See Tips for Success With a Motion for Approval of Disputed Charge.
Examples of evidence include copies of billing statements, explanations of benefits, their fee
schedules and/or affidavits from which the Commission can conclude that the charges are the
same regardless of whether the injury or illness arose out of and in the course of the patient’s
employment or otherwise.
Whenever possible, it is helpful to submit evidence that the charge falls within the 90th
percentile of other Idaho providers. If such evidence is not available, the Commission may
determine whether the disputed charge is “customary” based on a survey of Idaho Provider
charges.
The Provider should submit evidence that it complied with all applicable timelines and that the
Payor did not.
A Provider’s Motion should also contain evidence that the Provider’s charge is its “usual”
charge, even if the only issue appears to be based on timeliness. Commission staff will
determine if the charge submitted in the Motion is “customary” as well.
As with any other Motion, the Provider should submit evidence that the disputed charge is its
“usual” charge for that service, or a similar service.
When a service is not CPT-coded, or is unusual/exceptional, reasonableness is determined based
on all relevant evidence available. The Provider should submit documentation relating to and/or
supporting the reasonableness of its charge for the service.
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