Dateline: NH, June 2018
Are Medical Providers Charging Workers’ Comp A Reasonable Fee for Their Services?
Peter Sheffer. Workers’ Compensation Trust Director
Your injured worker may have brought a letter to you that they received from the NHADA Workers’ Compensation Trust (WCT) claims department regarding the partial payment of a medical bill. That employee may be concerned that they are responsible for the balance of the unpaid charges, or they may wonder where the check is that was supposed to be enclosed, or they may ask why workers’ comp is not paying the full amount of the bill.
First, the injured employee is not responsible for the balance of the unpaid charges. Second, the letter is a copy of an original letter that was sent to the medical provider, which included the check. Third, we are not paying the full amount of the medical provider’s charges because on September 5, 2015, the Governor signed a bill, which significantly amended the NH Workers’ Compensation statute.
The change came after New Hampshire businesses raised concerns to the Governor about the high cost of medical treatment associated with workers’ compensation claims, particularly when compared to non-workers’ compensation costs for the same types of treatment. NHADA and other businesses strongly advocated in the NH Legislature for a workers’ compensation fee schedule similar to those in place in 44 other states in the country.
In lieu of a fee schedule, medical providers successfully advocated for a change in the workers’ compensation statute to shift the burden of proof from the workers’ compensation carriers to the medical providers to prove that their charges for services were reasonable. The workers’ compensation statute had previously required the workers’ compensation carrier to pay the total charge unless they could prove that the charges were not reasonable. The medical providers who pushed for this change instead of the fee schedule, argued that the change would encourage negotiations between the parties. With negotiation, the disparity between what workers’ compensation pays and what everyone else pays would be greatly reduced.
The challenge the new statute creates for carriers is in determining what a reasonable charge for the services provided should be. “Reasonable” is undefined by the law. The WCT claims department checked with different resources and found the Comprehensive Listing of Current UCR and Medicare Fees with Relative Value Units, published by Practice Management Information Corporation.
According to the forward of the publication, “The UCR fees listed in this publication are derived from an analysis of over 600 million actual charges.” The intent of the publication is to assist medical practices with analyzing and adjusting their fees.
The WCT claims department has been paying providers based on the 50th percentile of the PMIC Comprehensive Listing of Current UCR and Medical Fees with geographical adjustment for New Hampshire since November 2016. Many providers fall at or below this level while others fall above it. The provider has the right to challenge the payment. In some cases, providers have been willing to negotiate a reduced charge, while others have refused to accept anything less than 100 percent of charges. If the parties are unable to reach a resolution, the medical provider has the right to request a hearing with the NH Department of Labor (NH DOL). The statute states that the Commissioner of Labor has exclusive jurisdiction in determining the reasonable value of the services provided.
Though some providers have initially sought hearings to challenge, no hearing has gone forward on a WCT disputed bill as the providers have dropped their hearing requests. The medical providers have 18 months from the date of the original denial — a copy of which the injured employee receives — to request a hearing with the NH DOL to contest the bill.
If you have any questions regarding this billing process or any other aspect of workers’ compensation, please contact me at 800-852-3372 or send and email to email@example.com.