(1) The purpose in developing utilization rules is to assure that appropriate quality and cost effective medical services are available to individuals injured on the job. Health care programs outside the workers' compensation arena such as the federal Medicare and Medicaid programs, as well as private health insurers, have had medical cost containment measures in place for some time. While reimbursement for medical services will continue to be based on fee schedules, the need for cost containment measures similar to those implemented in the nonworkers' compensation area has been recognized.
(2) The purpose of evidence-based utilization and treatment guidelines is to assist injured workers in receiving prompt and appropriate care, assist injured workers in stay-at-work/return-to-work options, assist clinicians in making decisions for specific conditions, and help insurers make reimbursement determinations. Although the primary purpose of the guidelines is advisory and educational, the guidelines are enforceable for payment purposes. The department recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.
History: 39-71-203, MCA; IMP, 39-71-704, MCA; NEW, 1993 MAR p. 404, Eff. 4/1/93; AMD, 2011 MAR p. 1137, Eff. 6/24/11.