About

In 2016, HB378 (Delegate Peter Farrell) passed the Virginia General Assembly. HB378 directed the Workers’ Compensation Commission (WCC) to adopt regulations establishing fee schedules for medical services to an injured person pursuant to the Virginia Workers’ Compensation Act. The MSV has since then been involved in the process of developing these regulations. This regulatory process setting reimbursement, costs for pharmaceuticals, costs for durable medical equipment, awards of attorney fees, peer review of medical costs, prior authorization for medical services and other issues determined by the WCC. It is vital that physicians, practice managers, and hospital administrators - who provide and administer workers’ compensation services - play a part in this process.

The Virginia Worker's Compensation Fee Schedule

Workers’ Compensation (WC) legislation requires an inflation adjustment in 2019. The Commission has hired the actuarial firm Oliver Wyman to develop the initial fee schedule. There are a number of new codes that will need to be added to the schedule. 

A recent update to the E-billing regulation was approved by the Commission on September 18, 2018.  Many of you have inquired, the VWC website will include a link to the updates in the Regulations.  The key points are listed below:

  • The requirement for 12/31/2018 implementation changed to voluntary with a required date in July, 2019.
  • Provider/Payer exclusions further defined
  • Standards of communication further defined
  • Contested/Denied language further aligned with statute

About

In December, physicians will receive what the new fee schedule will be for care after 2019 to be able to adjust or update your current reimbursement model.  After this inflation adjustment, the future inflation adjustments will occur every two years.

The Virginia fee schedule was constructed based upon what providers were reimbursed in the 2014-2015 time frames and NOT Medicare. Before the fee schedule was implemented, there was little incentive for a provider to contract with a WC carrier due to the ability to be paid the prevailing community rate (defined as billed charges). The pendulum appears to have swung back now as some providers (family physicians, orthopedic group and at least one Richmond hospital system) have approached a major WC third party administrator and offered to contract with them in exchange for payment in the amount of 75 percent of the WC fee schedule.

Fee Disputes Reported to the Commission

The number of fee disputes reported to the Commission have been just over 100.  The Commission navigates the disputes via education along the lines of what is billed and what the fee schedule says you must pay.  The Commission offers educational courses on billing and the fee schedule around the state.  Two educational courses remain to be scheduled. The Commission has received 367 questions on the fee schedule from physicians, hospitals, carriers and TPAs since January.

Legislation Requirements

The 2016 Workers’ Compensation legislation included the requirement for electronic billing, claims, case management, health records and supporting documentation. The requirement will go into effect no later than December 31, 2018. 

The Workers' Compensation Commission has developed a proposed regulation to provide a legal framework for electronic billing, processing, and payment of medical services and products provided to an injured worker subject to the Virginia Workers' Compensation Act. Public comment on these proposed regulations is now closed.

View the Proposed Regulations

Survey Information Used toward Sliding Scale Ranges

The regulatory advisory panel has asked MSV to survey providers to gather data on 714 fees, their frequency and amounts. 

714 fees are fees paid to claimant attorneys when they assist in obtaining payment for health care services in a case where the employer or insurance carrier has denied liability.

There are no current means to track the amount of 714 fees that are paid by providers. Often, a claimant’s attorney will contact a provider and negotiate the amount of the fees.

Some fee amounts are rumored to be as low as 15% of the provider’s bill recovered to as high as 40%. While the Workers Compensation Commission has authority to adjudicate disputes over 714 fees, rarely are they called upon to do so.

Complete the Survey

Resources

Medical Fee Services Newsletter 3rd Quarter 2018

Medical Fee Services Newsletter 2nd Quarter 2018