Billing review service standards
Sec. 5.2. (a) A billing review service shall adhere to the following
requirements to determine the pecuniary liability of an employer or
an employer's insurance carrier for a specific service or product
covered under worker's compensation:
(1) The formation of a billing review standard, and any
subsequent analysis or revision of the standard, must use data
that is based on the medical service provider billing charges as
submitted to the employer and the employer's insurance carrier
from the same community. This subdivision does not apply
when a unique or specialized service or product does not have
sufficient comparative data to allow for a reasonable
comparison.
(2) Data used to determine pecuniary liability must be compiled
on or before June 30 and December 31 of each year.
(3) Billing review standards must be revised for prospective
future payments of medical service provider bills to provide for
payment of the charges at a rate not more than the charges made
by eighty percent (80%) of the medical service providers during
the prior six (6) months within the same community. The data
used to perform the analysis and revision of the billing review
standards may not be more than two (2) years old and must be
periodically updated by a representative inflationary or
deflationary factor. Reimbursement for these charges may not
exceed the actual charge invoiced by the medical service
provider.
(4) The billing review standard shall include the billing charges
of all hospitals in the applicable community for the service or
product.
(b) A medical service provider may request an explanation from
a billing review service if the medical service provider's bill has been
reduced as a result of application of the eightieth percentile or of a
Current Procedural Terminology (CPT) coding change. The request
must be made not later than sixty (60) days after receipt of the notice
of the reduction. If a request is made, the billing review service must
provide:
(1) the name of the billing review service used to make the
reduction;
(2) the dollar amount of the reduction;
(3) the dollar amount of the medical service at the eightieth
percentile; and
(4) in the case of a CPT coding change, the basis upon which
the change was made;
not later than thirty (30) days after the date of the request.
(c) If after a hearing the worker's compensation board finds that
a billing review service used a billing review standard that did not
comply with subsection (a)(1) through (a)(4) in determining the
pecuniary liability of an employer or an employer's insurance carrier
for a health care provider's charge for services or products covered
under worker's compensation, the worker's compensation board may
assess a civil penalty against the billing review service in an amount
not less than one hundred dollars ($100) and not more than one
thousand dollars ($1,000).
As added by P.L.216-1995, SEC.3. Amended by P.L.202-2001,
SEC.4.
Last modified: May 27, 2006