Maine
Workers’ Compensation
Medical Fee Schedule
Maine Workers’ Compensation Board
Office of Medical/Rehabilitation Services
Presentation to the Maine Chapter of the
Healthcare Financial Management Association
November 15, 2012
Fish or cut
bait.
(American)
something that
you say to
someone when
you want them
to make a
decision and
take action
without any
more delay
NCCI State Advisory Forum 10/20/11
Total Benefit Costs
Medical
57%
Indemnity
43%
OVERVIEW
• Claim frequency
continues to decline
but appears to be
leveling off.
•
Medical benefits
constitute the majority
of total benefit costs in
Maine.
© Copyright 2011. National Council on Compensation Insurance, Inc. All rights reserved.
WCRI
 “States with fee schedule regulations that were based
on percent of charges had higher costs compared to
states with other types of fee schedules.”
 “As costs for workers’ compensation medical care
continue to increase rapidly, the pressure on
policymakers and other stakeholders to contain those
medical costs also continues to increase.”
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125
Maine State Legislature
 An Act Regarding Payment of Medical Fees in
the Workers’ Compensation System
 Stated Goal:

“…to ensure appropriate limitations on the
cost of health care services while
maintaining broad access for employees to
health care providers in the State…”
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125
Maine State Legislature
 The Board shall adopt rules that establish a
medical fee schedule setting the fees for
medical and ancillary services and products
rendered by individual health care
practitioners and health care facilities.
125th Maine State Legislature

The Board shall adopt rules that establish a
fee schedule or other standards of
reimbursement for providers regarding
administrative, case management, medical and
legal and other activities unique to the
treatment of injured workers in the workers'
compensation system.
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125
Maine State Legislature
 L.D. 1244 signed into Public Law on June 14,
2011 by Governor LePage.
 P.L. 2011, c. 338 repealed and replaced the
Medical Fees; Reimbursement Levels section
of the Workers’ Compensation Act.
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125
Maine State Legislature
 The Board was tasked with adopting rules that
establish medical fee schedules by December
31, 2011.
 On November 8, 2011, the Board voted to
adopt rules in accordance with the law.
Board Rule Chapter 5
 The current iteration of the medical fee rule
became effective on December 11, 2011.
 The National Council on Compensation
Insurance, Inc. (NCCI) anticipates that the new
rules will generate significant savings with
respect to medical costs.
Board Rule Chapter 5
 Underlying Methodology
 Federal Centers for Medicare and Medicaid
Services:


Procedure Codes
Relative Weights/Values
 Conversion Factors or Base Rates
Required Updates
 The Act now requires two types of medical fee
schedule updates:
 Annual updates done by the Executive Director
of the Board
 Periodic updates undertaken by the Board
Workers’ Compensation Boards?
 Independent Board of
Directors composed of seven
members appointed by the
Governor:
 3 Representatives of
management
 Chamber of Commerce
and Industry
 3 Representatives of
labor
 AFL-CIO
 Chair (Executive Director)
 Executive Director
 9 Hearing officers
 General Counsel
 Deputy Director of
Business Services
 Deputy Director of
Information Services
 Deputy Director of
Medical/Rehabilitation
Services
 Senior Staff Attorney
Worker Advocate Division
Annual Updates
 Notwithstanding Title 5, Chapter 375,
Subchapter 2, the Executive Director of the
Board shall annually update the medical fee
schedule.
 Must be complete by December 31st of each
year.
Annual Updates
 The medical fee schedule must be consistent
with the most current medical coding and
billing systems:
 RBRVS
 HCPCS
 MSDRG
 ICD
 APC
 CPT
Annual Updates
 The exemption from rulemaking for the annual
updates is premised on two grounds:
 Ministerial nature of updates
 Inability to meet annual update timeline if
rulemaking undertaken
Fallback Provision
 If the Executive Director fails to annually
update the medical fee schedule, the
reimbursement rate for medical services is
105% of the private 3rd-party payor average
payment rate for the provider or the amount
agreed to in writing prior to the rendering of
service.
 Fallback provision is NOT A VIABLE OPTION!
Periodic Updates
 The Board shall undertake a comprehensive
review of the medical fee schedule once every
3 years beginning in 2014.
 These periodic updates are subject to the
rulemaking requirements of the APA.
Rulemaking Process
 Annual Regulatory Agenda
 Board drafts rules
 Governor’s office for pre-approval
 Attorney General’s office for legal pre-review
 Public Hearing


Oral testimony
Written testimony
Rulemaking Process continued…
 Board takes final action
 Governor’s office for post-approval (only if
amended)
 Attorney General’s office for legal postreview
 Filing with the Secretary of State

Effective date
Periodic Updates
The Board shall consider the following factors:
 The private 3rd-party payor average payment rates
obtained from the Maine Health Data Organization;
 Any material administrative burden imposed on
providers by the nature of the workers' compensation
system; and
 The goal of maintaining broad access for employees
to all individual health care practitioners and health
care facilities in the State.
Information Needed:
 Workers’ compensation payments compared
to private 3rd-party payor average payment
rates:
 Average total payments, including
professional, facility, ancillary and patient
cost-sharing contribution for the medical
and ancillary services and products most
commonly rendered during the immediately
preceding calendar year.
Information Needed:
 Material administrative burdens?
 M-1 and other narrative reports
 Depositions
 Medical records
 Billing for professional services directly
 Implants
 “Orphaned” medical bills
 Other
Information Needed:
 Average age of workers’ compensation
payments:
 Statute – Section 205.4

within 30 days after the carrier has received
notice of nonpayment by certified mail
 Rules and Regulations – Section 1.04

usual and customary charge or the maximum
allowable payment under this Medical Fee
Schedule, whichever is less, within 30 days of
receipt of a properly coded bill
Fish or Cut Bait.