HOME    SEARCH    ABOUT US    CONTACT US    HELP   
           
Montana Administrative Register Notice 24-29-252 No. 21   11/12/2010    
Prev Next

BEFORE THE DEPARTMENT OF LABOR AND INDUSTRY

STATE OF MONTANA

 

In the matter of the amendment of ARM 24.29.1432, 24.29.1533, and 24.29.1538, regarding the workers' compensation medical fee schedules

)

)

)

)

NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO:  All Concerned Persons

 

            1.  On December 3, 2010, at 10:00 a.m., or as soon thereafter as is feasible, the Department of Labor and Industry (department) will hold a public hearing to be held in the Sanders Auditorium of the DPHHS Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rules.

 

            2.  The department will make reasonable accommodations for persons with disabilities who wish to participate in this public hearing or need an alternative accessible format of this notice.  If you require an accommodation, contact the department no later than 5:00 p.m. on November 30, 2010, to advise us of the nature of the accommodation that you need.  Please contact the Employment Relations Division, Workers' Compensation Regulations Bureau, Attn: Keith Messmer, P.O. Box 8011, Helena, Montana 59624-8011; telephone (406) 444-6541; fax (406) 444-3465; TDD (406) 444-5549; or e-mail kmessmer@mt.gov.

 

            3.  The rules proposed to be amended provide as follows, stricken matter interlined, new matter underlined:

 

            24.29.1432  FACILITY SERVICE RULES AND RATES FOR SERVICES PROVIDED ON OR AFTER DECEMBER 1, 2008  (1) through (1)(f) remain the same.

(g)  The Montana Status Indicator (SI) Codes as follows: ; and

(i)  for services provided from December 1, 2008, through December 31, 2010, "The Montana Status Indicator (SI) Codes applicable from December 1, 2008, to December 31, 2010";

(ii)  for services provided on or after January 1, 2011, "The Montana Status Indicator Codes applicable on or after January 1, 2011"; and

            (h) and (2) remain the same. 

            (3)  Critical access hospitals and medical assistance facilities are reimbursed at 100 percent of that facility's usual and customary charges, unless there is an applicable agreement with a managed care organization or a preferred provider organization that provides for a different payment amount.

            (4) through (6) remain the same.

            (7)  Facility billing must be submitted on a CMS Uniform Billing (UB-04) form or CMS 1500 form, including the 837-l and 837-P form when submitting electronically.  When a billing document includes a line item charge, but no CPT or HCPCS code is provided for that item, the item is not separately payable.

            (8) through (10) remain the same.

            (11)  The following applies to inpatient services provided at an acute care hospital:

            (a)  The department may establish the base rate annually.

            (i)  Effective December 1, 2008 For services provided from December 1, 2008, through December 31, 2010, the base rate is $7,735.

            (ii)  For services provided on or after January 1, 2011, the base rate is $8,091.

            (b)  Payments for inpatient acute care hospital services must be calculated using the base rate multiplied by the Montana MS-DRG weight.  For example, for services on or after January 1, 2011, if the MS-DRG weight is 0.5, the amount payable is $3,867.50 4,045.50, which is the base rate of $7,735 8,091 multiplied by 0.5.

            (c) remains the same.

            (d)  The threshold for outlier payments is three times the Montana MS-DRG payment amount.  For services provided on or after January 1, 2011, when determining whether the outlier threshold has been met, the only implantable charges that may be included in the total charges are the actual invoice cost of the implantable, the handling and freight cost for the implantable, and 15 percent of the actual amount paid for the implantable.  Any reimbursement for an implantable included as part of an outlier must be documented by a copy of the invoice for the implantable.  If the outlier threshold is met, the outlier payment must be the MR-DRG reimbursement amount plus an amount that is determined by multiplying the charges above the threshold by the sum of 15 percent and the individual hospital's Montana operating RCC.

            (i) and (ii) remain the same.

            (e)  The following applies to implantables provided at an acute care hospital:

            (i)  For services provided from December 1, 2008, through December 31, 2010, Wwhere an implantable exceeds $10,000 in cost, hospitals may seek additional reimbursement beyond the normal MS-DRG payment according to (11)(e)(iii) through (v).  Any implantable that costs less than $10,000 is bundled in the implantable charge included in the MS-DRG payment.

            (ii)  For services provided on or after January 1, 2011, implantables are not separately reimbursed.

            (i)(iii)  Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable.  Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

            (ii)(iv)  Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid for the implantable.  Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

            (iii)(v)  When a hospital seeks additional reimbursement pursuant to this subsection, the implantable charge is excluded from any calculation for an outlier payment.

            (iv)(vi)  Because the decision regarding an implantable is a complex medical analysis, this rule defers to the judgment of the individual physician and facility to determine the appropriate implantable.  A payer may not reduce the reimbursement when the medical decision is to use a higher cost implantable.

            (f) and (g) remain the same.

            (12)  The following applies to outpatient services provided at an acute care hospital or an ASC:

            (a)  The department may establish the base rate for outpatient service at acute care hospitals annually.

            (i)  Effective For services provided from December 1, 2008, through December 31, 2010, the base rate for hospital outpatient services is $105.

            (ii)  For services provided on or after January 1, 2011, the base rate for hospital outpatient services is $102.40.

            (b)  The department may establish the base rate for ASCs annually.

            (i)  Effective For services provided from December 1, 2008, through December 31, 2010, the base rate for ASCs is $79, which is 75 percent of the hospital base rate.

            (ii)  For services provided on or after January 1, 2011, the base rate for ASCs is $76.80, which is 75 percent of the hospital base rate.

            (c) through (e) remain the same.

            (f)  The following applies to implantables provided as part of outpatient services at an acute care hospital or at an ASC:

            (i)  For services provided from December 1, 2008, through December 31, 2010, where Where an outpatient implantable exceeds $500 in cost, hospitals or ASCs may seek additional reimbursement beyond the normal APC payment according to (12)(f)(iii) through (iv).  In such an instance, the provider may bill CPT code L 8699, and the status indicator code "N" may not be used by a payer to determine the amount of the payment.  Any implantable that costs less than $500 is bundled in the APC payment.

            (ii)  For services provided on or after January 1, 2011, implantables are not separately reimbursable.

            (i)(iii)  Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable.  Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

            (ii)(iv)  Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid for the implantable.  Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

            (v)  Because the decision regarding an implantable is a complex medical analysis, this rule defers to the judgment of the individual physician and facility to determine the appropriate implantable.  A payer may not reduce the reimbursement when the medical decision is to use a higher cost implantable.

            (g) remains the same.

 

AUTH:  39-71-203, MCA

IMP:  39-71-203, 39-71-704, MCA

 

REASON:  There is reasonable necessity to amend ARM 24.29.1432 because 39-71-704, MCA, requires the department to annually establish a schedule of fees for medical services that are necessary for the treatment of injured workers.  Section 39-71-704, MCA, also controls workers' compensation costs by setting an upper limit above which fees may not be set.  The proposed rates change reimbursement for facilities in order to address steadily increasing medical costs in workers' compensation, costs that are increasing faster than general inflation.  Currently, medical costs comprise 72% of every dollar spent on workers' compensation benefits, compared to 56% in 1998.  The department initially established the current fee schedule to make reimbursement based on a cost-based system, so that costs could be controlled.  The proposed rates reimburse at approximately 150% of Medicare and are set relative to the limit of 10% above group health based on the data supplied by providers.  The proposed rates are higher than those discussed informally by the department because Medicare rates recently went up.  Further, although the department is analyzing Medicare rates as relevant to the fee schedule reimbursements, the department is proposing a Montana-specific rate that will not go down if Medicare reimbursement goes down.  Rather, this rate will only change if proposed and adopted through the normal Montana Administrative Procedure Act requirements.  The department reserves the right to adjust the proposed reimbursement rates based on comments received.

 

There is also reasonable necessity to change the reimbursement procedure for implantables.  Providers have indicated that they would prefer that the reimbursement amount for implantables be incorporated in the base rate reimbursement number, rather than have a separate reimbursement.  That allows providers to not have to process excess paperwork dealing with the implantable reimbursement.

 

There is also reasonable necessity to update the Montana-specific status indicator code list, in order to make the fee schedule simpler and clearer for users.  The updated list proposes to add more of Medicare's status indicator codes, since that it what users are accustomed to.

 

There is reasonable necessity to amend (3) to remove medical assistance facilities to conform to the statutory amendments to 39-71-704, MCA.  Because the department has received numerous inquiries regarding reimbursement for critical access hospitals, there is also reasonable necessity to clarify that under 39-71-704(8), MCA, critical access hospitals may be subject to lower than 100% reimbursement if that hospital chooses to enter into a managed care organization agreement or a preferred provider agreement.

 

Due to feedback from users, there is reasonable necessity to clarify that when a line item charge on a bill does not include a CPT or HCPCS code, it is not reimbursable at 75% of charges.  Rather, that item is not separately reimbursable.

 

            24.29.1533  NONFACILITY FEE SCHEDULE FOR SERVICES PROVIDED ON OR AFTER JANUARY 1, 2008  (1) through (1)(b)(i) remain the same.

            (ii)  For services provided on or after January 1, 2011, the Montana geographical practice cost indices (GPCI) listed in the RBRVS are incorporated by reference.

            (c) remains the same.

(i)  The "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2009", applies to services provided from January 1, 2009, through December 31, 2009.;

            (ii)  The "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2008", September 2007 edition, applies to services provided from January 1, 2008, through December 31, 2008;.

            (d) through (f) remain the same.

            (2)  The conversion factors, the CPT codes, and the RVU, and the GCPI used depends on the date the medical service, procedure, or supply is provided.  The reimbursement amount is generally determined by finding the proper CPT code in the RBRVS then multiplying the GPCI adjusted RVU for that code by the conversion factor.  For example, if the conversion factor is $5.00, and a procedure code has a GPCI adjusted unit value of 3.0, the most that the insurer is required to pay the provider for that procedure is $15.00.

            (3)  Instructions for the fee schedule are available on the department's web site, along with already calculated reimbursement amounts by CPT code.  All the definitions, guidelines, RVUs, procedure codes, modifiers, and other explanations provided in the instructions affecting the determination of individual fees apply.  A copy of the instructions is available on the department web site at http://erd.dli.state.mt.us/wcregs/medreg.asp or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

            (4)  The maximum fee that an insurer is required to pay for a particular procedure is listed on the department web site and was computed using the RVU in the total facility or nonfacility column of the RBRVS times the conversion factor, except as otherwise provided for in these rules.

            (5) remains the same but is renumbered (4).

            (6)  RVUs have not been established in the RBRVS for CPT codes 99455 and 99456.  The RVU established by the department for:

            (a)  code 99455 is 2.5 RVU; and

            (b)  code 99456 is 2.8 RVU.

            (7) through (11) remain the same but are renumbered (5) through (9).

 

AUTH:  39-71-203, MCA

IMP:  39-71-704, MCA

 

REASON:  There is reasonable necessity to amend 24.29.1533 to incorporate the geographical practice cost indices that are incorporated in the RBRVS.  The department has determined that because geographical practice cost indices are an integral part of the overall RBRVS system, including the indices within the Montana fee schedule system will increase the overall comparability to Medicare and other payers.

 

There is reasonable necessity to remove the requirement from rule that the already calculated maximum reimbursement amounts that an insurer is required to pay be listed on the department's web site by CPT code.  The department cannot list these amounts at the same time as the rules notice is posted because the timing the rules notice and the RVU value changes are different.  Therefore, the department proposes to remove the mandatory requirement from the rule, but still post the values in a timely manner as a customer service.

 

There is reasonable necessity to remove the Montana-specific RVU values for the listed codes because the RBRVS has now established values for those codes.

 

            24.29.1538  CONVERSION FACTORS FOR SERVICES PROVIDED ON OR AFTER JANUARY 1, 2008 -- METHODOLOGY  (1) and (2) remain the same.

            (a)  provided from January 1, 2008, through December 31, 2008, is $63.45; and

            (b)  provided on or after from January 1, 2009, through December 31, 2010 is $65.28; and

            (c)  provided on or after January 1, 2011, is $59.81.

            (3) and (3)(a) remain the same.

            (b)  provided from January 1, 2009, through December 31, 2009, is $61.98; and

            (c)  provided on or after from January 1, 2010, through December 31, 2010 is $60.97; and

            (d)  provided on or after January 1, 2011, is $55.12.

            (4) and (5) remain the same.

 

AUTH:  39-71-203, MCA

IMP:  39-71-704, MCA

 

REASON:  There is reasonable necessity to amend ARM 24.29.1538 because 39-71-704, MCA, requires the department to annually establish a schedule of fees for medical services that are necessary for the treatment of injured workers.  The statute allows the rate to be set at a rate not greater than 10% above the average of the conversion factors used by up to the top five insurers or third party administrators providing group health insurance coverage using the resource-based relative value scale in Montana.  The 2011 average rate is $62.41.  The proposed rate is therefore 96% of group health rates and 87% of the upper limit of 68.65.  The proposed rate is set relative to 10% above the average conversion factor.  The department believes this is a reasonable conversion factor that controls costs but at the same time provides a reasonable reimbursement.  Because Montana's group health rates are more than 115% of the national average for group health, the department believes that setting the rate at the maximum limit of 110% of group health in Montana will not properly control costs.

 

The proposed rates change reimbursement for nonfacilities in order to address steadily increasing medical costs in workers' compensation, costs that are increasing faster than general inflation.  Currently, medical costs comprise 72% of every dollar spent on workers' compensation benefits which is significantly above the national average and up from 56% in 1998.  The department initially established the fee schedule to have reimbursement based on a cost-based system, so that costs could be controlled.  Setting the conversion factor at a lower amount is intended to balance the competing interests of users of the system in that it controls costs, but also allows for a reasonable reimbursement above costs.

 

The proposed rates are higher than those discussed informally by the department because Medicare rates recently went up.  Further, although the department is analyzing Medicare rates as relevant to the fee schedule reimbursements, the department is proposing a Montana-specific rate that will not go down if Medicare reimbursement goes down.  Rather, this rate will only change if proposed and adopted through the normal Montana Administrative Procedure Act requirements.  The department reserves the right to adjust the proposed reimbursement rates based on comments received.

 

            4.  Concerned persons may present their data, views, or arguments, either orally or in writing, at the hearing.  Written data, views, or arguments may also be submitted to:  Keith Messmer, Bureau Chief, Workers' Compensation Regulations Bureau, Employment Relations Division, Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59624-8011; telephone (406) 444-6541; fax (406) 444-3465; TDD (406) 444-5549; or e-mail kmessmer@mt.gov, and must be received no later than 5:00 p.m., December 10, 2010.

 

            5.  An electronic copy of this Notice of Public Hearing is available through the department's web site at http://dli.mt.gov/events/calendar.asp, under the Calendar of Events, Administrative Rules Hearings section.  The department strives to make the electronic copy of this Notice of Public Hearing conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered.  In addition, although the department strives to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems, and that a person's difficulties in sending an e-mail do not excuse late submission of comments.

 

            6.  The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency.  Persons who wish to have their name added to the list shall make a written request which includes the name and mailing address of the person to receive notices and specifies that the person wishes to receive notices regarding all Department of Labor and Industry administrative rulemaking proceedings or other administrative proceedings.  Such written request may be mailed or delivered to the Department of Labor and Industry, attention:  Mark Cadwallader, 1327 Lockey Avenue, P.O. Box 1728, Helena, Montana 59624-1728, faxed to the department at (406) 444-1394, e-mailed to mcadwallader@mt.gov, or may be made by completing a request form at any rules hearing held by the agency.

 

            7.  The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

 

            8.  The department's Hearings Bureau has been designated to preside over and conduct the hearing.

 

/s/ MARK CADWALLADER                                    /s/ KEITH KELLY

Mark Cadwallader,                                                   Keith Kelly,

Alternate Rule Reviewer                                           Commissioner of Labor and Industry

 

            Certified to the Secretary of State November 1, 2010

 

Home  |   Search  |   About Us  |   Contact Us  |   Help  |   Disclaimer  |   Privacy & Security