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Medical fee schedule tweaks in store for several states


A handful of states are now considering or have already adopted medical fee schedule changes in workers compensation — changes that could boost rates but are necessary to keep providers in the system, experts say.

But don’t expect major changes in costs and rates for comp, said Jeff Eddinger, Boca Raton, Florida-based senior division executive for the National Council on Compensation Insurance, who estimates annual adjustments for most fee schedules that update every year “are usually very small, less than 1%.” Some states call for adjustments every few years, but those adjustments fall in the 1% to 5% range in cost increases, he said.

Many of the changes are in line with state regulations — which call for annual updates — and some are established in relation to federal Medicare’s fee schedule for medical care and procedures.

As of early February, California, Nebraska, Ohio, Oklahoma and South Carolina are expected to make adjustments, according to announcements in those states that put the changes in line with state laws. Fee schedules use a coding system to help payers know what services were performed and where, and for what kind of provider.

Officials in California, Nebraska and South Carolina said the changes are expected to be minor. Ohio officials did not return requests for more information on changes there. Oklahoma lawmakers filed several comp-related bills in January, with at least one dealing with the medical fee schedule, adding chiropractic care.

A February 2020 legislative analysis by Coventry Workers’ Comp Services notes that lawmakers in one state could consider an overhaul. Legislation in New Jersey would establish a new medical fee schedule that takes into account geography and sets forth a procedure for petitioning the state Workers’ Compensation Commission if a “maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care,” according to a draft of H.B. 2792. The bill stalled in 2019 but could be revived.

Mr. Eddinger said discussions on medical fee schedules have become increasingly popular because of debates on care and access. 

“One of the things that a fee schedule does, it reduces disputes because there are rules on the prices that can be paid,” he said.

Updates are necessary, according to Robin Gelburd, president of New York-based FAIR Health Inc., a data analytics firm that helps states establish and update fee schedules. Telemedicine for injured workers suffering musculoskeletal disorders “is an area that many states are reviewing,” she said. Texas added telemedicine to its fee schedule in 2018.

An “updated fee schedule contributes to a common understanding of payment rules and reimbursement levels, which minimizes challenges and disputes and reduces administrative static,” she said.

“Each state has different goals, structure and frequency of updating their fee schedules,” she said.