Medical Fee Schedule Education Session July 20, 2018

1. Medical Fee Schedule Education Session July 20, 2018 Virginia Workers’ Compensation Commission Medical Fee Services Department

2. Virginia Workers’ Compensation Commission • Welcome • Chairman, Ferrell Newman

3. Medical Fee Services Department In-service Education SessionAgenda • Introductions • Objectives • MFS “Nuts and Bolts” and Medical Service Coding • Requirements and Process for MFS Updates • MFS Reference Tools • Medical Reimbursement Dispute Resolution • Closing Remarks

4. Introductions • MFS Department • Manager • Drema Thompson • Analysts • Chris Branham • Hope Hill • Rachel Mcllyar • Contact: medicalfeeservices@workcomp.virginia.gov • 877-664-2566 extension 4165

5. Objectives • Promote understanding of “nuts and bolts” of the medical fee schedule and 65.2-605 regulations and provide a practical process to apply the medical fee schedule. • Provide insight into the requirements and process for MFS updates and how they will happen. • Apply the medical fee schedule look up tool for everyday practice. • Demonstrate use of medical reimbursement dispute resolution steps to manage disagreements that may occur between stakeholders.

6. Nuts and BoltsSuu Section 65.2-605 • Employer Liability for medical treatment expanded to include… • Maximum Fee Reimbursement • Rulemaking for Application of the maximum fee • Provider Categorization • Coding for Medical Services • Exclusions

7. Area of Specialty • Provider Categorization (as mandated in § 65.2-605, Ground Rules, and final regulations) • Surgeon vs. Physician Non-Surgeon • 1Taxonomy • Taxonomy codes are self-selected by the health care provider. • These codes are for health care providers that are enrolled with Payers. • Taxonomy codes are not used to define services rendered, they are used to define area of specialty. • Facility vs. Professional • 1. What medical services were provided? • Make sure code selected = service

8. Applicable Coding Conventions (ACC) Place of Service Primary Coding System Inpatient (HI) Rehabilitation Facility Outpatient (HO) Ambulatory Surgery Center (ASC) Professional Services DRG’s DRG, Revenue, CMG Current Procedural Terminology (CPT) and Healthcare Common Procedures Coding System (HCPCS) Level II

9. MFS -Practical Application (PA) • How is reimbursement determined for out of state providers? The applicable community for providers of medical services rendered outside of the Commonwealth shall be determined by: (a) zip code of the principal place of business of the employer if located in the Commonwealth or, (b) if no such location exists, the zip code of the location where the Commission hearing regarding a dispute concerning the services would be conducted.

10. MFS PA conti.. Source: National Uniform Claim Committee, www.nucc.org

11. MFS Updates: How will they happen? • Formal Review Process • The Commission’s formalized review process will include:  • (1) Regulatory Advisory Panel recommendation for adjustments, • Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) applicable changes • MFS Experience Stakeholder feedback • Identified errors or omissions • (2) Inflation or deflation impacts attributed to the Consumer • Price Index for All Urban Consumers (CPI-U), and • (3) The biennial peer reviewed studies reflecting impacts in • Virginia’s workers’ compensation system medical cost • comparison studies obtained as required for either the • transition or biennial review periods.  • **There will be an opportunity for public comment before any revisions are made to the MFS and MFS regulations.

12. Medical Fee Schedule Reimbursement Look-up Tool The MFS Look-up Tool was created to simplify the reimbursement look up process for providers and payers. VA Workers’ Compensation Commission

13. Medical Fee Services eNews

14. Medical Provider Inquiries are handled by MFS Department • Medical Provider Inquiries will soon be electronically fillable simplifying inquiry submissions

15. Reference Tools www.workcomp.virginia.gov

16. Medical Reimbursement Dispute Resolution

17. Managing Interpretive Differences

18. Source of Differences

19. MFS Department • Communication • Feedback • Decisions • Balance

20. MFS Dispute Resolution Process

21. Administrative Decision • Your right to appeal • If any party disagrees with the administrative decision of the Medical Fee Service Department , it may request a hearing before a Deputy Commissioner provided such a request is made in writing within 30 days.

22. § 65.2-605.1. Payment and Denials • Payment for health care services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. • If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer's workers' compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. • The notification shall include the following information: • 1. The reasons for contesting or denying the itemization, or the reasons the itemization is considered incomplete; • 2. If the itemization is considered incomplete, all additional information required to make a decision; and • 3. The remedies available to the health care provider if the health care provider disagrees.

23. Questions

24. Closing Remarks • Director, Evelyn McGill