FAQ: Med Fee Disputes

The following questions pertain to the rules and regulations governing charges for medical services provided under the Idaho Workers’ Compensation Law IDAPA 17.02.08.031 and 17.02.08.032.

The Idaho Industrial Commission adopted 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 under the Idaho Worker’s Compensation Law by providers other than hospitals and ambulatory surgical centers (ASCs).

The FAQ is broken into four sections:

•  Definitions
•  Billings
•  Documentation
•  Forms

Definitions

•  What is an acceptable 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.

     

    In accordance with IDAPA 17.02.08.031.02(b), the conversion factors are to be applied to the fully‑implemented facility or non‑facility 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.
     

  •  Effective 4‑02‑08, the fee schedule found in IDAPA 17.02.08.031 governs the acceptable charge for medical services.
     

  •  Medical services provided between 3‑15‑07 and 4‑01‑08 are subject to a previous temporary fee schedule adopted 3-15-07. 

     

  •  Medical services provided between 4‑01‑06 and 3‑14‑07 are subject to a previous temporary fee schedule adopted 4-01-06.

     

  •  All medical services preceding 4-01-06 are subject to usual and customary charges.
     
•  What is a reasonable charge?
   
  •  A reasonable charge does not exceed the Provider’s “usual” charge and does not exceed the “customary” charge.
     
•  What is a Provider’s usual 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.
     

•  What is a customary charge?
   
  •  A customary charge shall have an upper limit no higher than the 90^th percentile, as determined by the Commission, of usual charges made by Idaho Providers for a given medical service.

    
     

•  What are medical services? Are pharmaceutical drugs included as a 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.

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Billings

•  What are the acceptable charges for hospitals and ambulatory surgical centers (ASCs)?*
   
  •  Large hospitals (> 100 beds): 85% of the appropriate inpatient charge.
  •  Small hospitals (≤ 100 beds): 90% of the appropriate inpatient charge.
  •  Ambulatory surgical centers and hospital outpatient charges: 80% of the appropriate charge.
    
    * For a list of hospitals, and the number of beds in the facility, click here.
     
•  What is the acceptable charge for surgically implantable hardware?
   
  •  Surgically implantable hardware is paid at the rate of actual cost plus 50%.
     
•  Are CPT codes required for billing physician services? Are modifiers required?
   

  • Whenever possible, a Provider’s bill for services shall 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 [see IDAPA 17.02.08.032.03 (a)].
     

•  What are medical reports as referenced in the IDAPA rule?
   

  • 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.  [see IDAPA 17.02.08.032.03 (c)].
    
    NOTE: This is not an exclusive list.
     

•  Does the medical report have to be sent at the same time as the bill for services? What happens if the report does not accompany the bill?
   

  • 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 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 17.02.08.032.03(c)].

     

    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.

    
     
•  Is a Provider required to provide invoices to the Payor? What happens if the invoices are not provided after the Payor has made a timely request?
   

  • 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 17.02.08.032.06(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 71.02.08.032.07(c)].

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Documentation

•  What forms are required when filing a Motion for Approval of Disputed charges? To whom should the Motion be sent?
   
  •  

    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.
     

•  What types of evidence should be sent to establish that the charge is “usual?”
   

  • 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.
     

•  Is it necessary to submit evidence that the charge is “customary?”
   
  •  No, the Commission will determine whether the disputed charge is “customary” based on the Commission’s compilation of Idaho Provider charges.
     
•  If the dispute concerns a Payor’s failure to comply with timelines, what types of documentation should be submitted with the Motion?
   
  •  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 chare 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.

    
     

•  What types of documentation must be submitted when the medical service in dispute is not CPT-coded, or is unusual/exceptional?
   
  •  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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Forms

•  Motions in medical fee disputes:
   
  •  Motion for Approval of Disputed Charge (Adobe Acrobat)

  • Response to Motion for Approval of Disputed Charge (Adobe Acrobat)

  • Motion to Present Additional Evidence (Adobe Acrobat)

  • Motion for Reconsideration (Adobe Acrobat)

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