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DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS’ COMPENSATION AGENCY
WORKERS’ COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on December 17, 2012
These rules become effective 7 days after filing with the Secretary of State
(By authority conferred on the workers’ compensation agency by sections 205 and 315 of 1969 PA 317, section 33 of 1969 PA 306, Executive Reorganization Order Nos. 1982-2, 1986-3, 1990-1, 1996-2,
2003-1, and 2011-4, MCL 418.205, 418.315, 24.233, 18.24, 418.1, 418.2, 445.2001, 445.2011, and
445.2030)
R 418.10101, R 418.10107, R 418.10108, R 418.10208, R 418.10209, R 418.101002a, R 418.101003a,
R 418.101207, and R 418.101303, of the Michigan Administrative Code are amended as follows:
R 418.10101 Scope.
Rule 101. (1) These rules do all of the following:
(a) Establish procedures by which the employer shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable medical, surgical, and hospital services and medicines, or other attendance or treatment recognized by the laws of the state as legal, when needed. The employer shall also supply to the injured employee dental services, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances necessary to cure, so far as reasonably possible, and relieve from the effects of the injury.
(b) Establish schedules of maximum fees by a health facility or health care provider for such treatment or attendance, service, device, apparatus, or medicine.
(c) Establish procedures by which a health care provider shall be paid.
(d) Provide for the identification of utilization of health care and health services above the usual range of utilization for such services, based on medically accepted standards, and provide for acquiring by a carrier and by the workers'
compensation agency the necessary records, medical bills, and other information concerning any health care or health service under review.
(e) Establish a system for the evaluation by a carrier of the appropriateness in
terms of both the level of and the quality of health care and health services provided to injured employees, based upon medically accepted standards.
(f) Authorize carriers to withhold payment from, or recover payment from, health facilities or health care providers, which have made excessive charges or which have required unjustified treatment, hospitalization, or visits.
(g) Provide for the review by the workers' compensation agency of the records and medical bills of any health facility or health care provider which have been determined by a carrier not to be in compliance with the schedule of charges established by these rules or to be requiring unjustified treatment, hospitalization, or office visits.
(h) Provide for the certification by the workers' compensation agency of the carrier's professional utilization review program.
(i) Establish that when a health care facility or health care provider provides health care or health care service that is not usually associated with, is longer in duration than, is more frequent than, or extends over a greater number of days than that health care or service usually does with the diagnosis or condition for which the patient is being treated, the health facility or health care provider may be required by the carrier to explain the necessity in writing.
(j) Provide for the interaction of the workers' compensation agency and the department of licensing and regulatory affairs for the utilization of departmental procedures for the resolution of workers' compensation disputes.
(k) Are intended for the implementation and enforcement of section 315(2) to
(9) of the act, provide for the implementation of the workers' compensation agency's review and decision responsibility vested in it by those statutory provisions. The rules and definitions are not intended to supersede or modify the workers’ disability compensation act, the administrative rules of practice of the workers' compensation agency, or court decisions interpreting the act or the workers' compensation agency's administrative rules.
(2) An independent medical examination shall be exempt from these rules and may be requested by a carrier or an employee. An independent medical examination, (IME), shall be conducted by a practitioner other than the treating practitioner. Reimbursement for the independent medical evaluation shall be based on a contractual agreement between the provider of the independent medical evaluation and the party requesting the examination.
(3) These rules and the fee schedule shall not pertain to health care services which are rendered by an employer to its employee in an employer-owned and employer-operated clinic.
(4) If a carrier and a provider have a contractual agreement designed to reduce the cost of workers' compensation health care services below what would be the aggregate amount if the fee schedule were applicable, the contractual agreement shall be exempt from the fee schedule. The carrier shall be required to do both of the following:
(a) Perform technical and professional review procedures.
(b) Provide the annual medical payment report to the health care services division of the workers' compensation agency.
R 418.10107 Source documents; adoption by reference.
Rule 107. The following documents are adopted by reference in these rules and are available for inspection and distribution from the Workers' Compensation Agency, Health Care Services Division,
P.O. Box 30016, Lansing, Michigan 48909, at the cost listed in subdivisions (a) to (g) of this rule, or directly from the organizations listed:
(a) "Physicians' Current Procedural Terminology (CPT®) 2012," professional edition, copyright October 2011, published by the American Medical association, PO Box 930884, Atlanta GA, 31193- 0884, order EP888812, 1-800-621-8335. The publication may be purchased at a cost of $109.95 plus
$16.95 shipping and handling as of the time of adoption of these rules. Permission to use this publication is on file in the workers' compensation agency.
(b) "Medicare's National Level II Codes, HCPCS, 2012:" copyright December 2010, published by the American Medical Association, P.O. Box 930884 Atlanta GA 31193-0884, order OP231512, customer service 1-800-621-8335. The publication may be purchased at a cost of $96.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.
(c) "Medicare RBRVS 2011: The Physicians' Guide," published by The American Medical Association.
(d) "Medicare RBRVS 2012: The Physicians' Guide," published by The American Medical Association,
P.O. Box 930884, Atlanta GA 31193-0884, order #OP059612 1-800-621-8335. The publication may be
purchased at a cost of $91.95, plus $11.95 shipping and handling is of the time of adoption of these rules.
(e) "International Classification of Diseases, ICD 9 CM 2012 Volumes 1 and 3 Data File Download," copyright October 2011, American Medical Association, P.O. Box 930884, Atlanta GA 31193-0884, order # DL050812, 1-800-621-8335.
(f) Red Book Online subscription service of Truven Health Analytics, contact: http://www.redbook.com/redbook/online/.
(g) "Official UB-04 Data Specifications Manual 2012(v. 3.00), July 1, 2011" developed in cooperation with the American Hospital Association's National Uniform Billing committee, published by American Hospital Association, National Uniform Billing Committee - UB-04, P.O. Box 92247, Chicago, IL 60675-2247, 1-312-422-3390. As of the time of adoption of these rules, the cost of the publication is
$150.00.
R 418.10108 Definitions; A to I. Rule 108. As used in these rules:
(a) "Act" means 1969 PA 317, MCL 418.101 et seq.
(b) "Adjust" means that a carrier or a carrier's agent reduces a health care provider's request for payment to the maximum fee allowed by these rules, to a provider's usual and customary charge, or, when the maximum fee is by report, to a reasonable amount. "Adjust" also means when a carrier re- codes a procedure, or reduces payment as a result of professional review.
(c) "Agency" means the workers' compensation agency in the department of licensing and regulatory affairs.
R 418.10208 Vision services.
Rule 208. (1) A medical diagnostic eye evaluation by a practitioner is an integral part of all vision services.
(2) Intermediate and comprehensive ophthalmological services include medical diagnostic eye evaluation and services, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, determination of refractive state, tonometry, or motor evaluation. These procedures shall not be billed in conjunction with procedure codes 92002, 92004, 92012, and 92014.
(3) Only an ophthalmologist or a doctor of optometry shall use procedure codes 92002, 92004, 92012, and 92014.
(4) A doctor of optometry shall use procedure codes 92002-92287 to describe services.
(5) An employer is not required to reimburse or cause to be reimbursed charges for an optometric service unless that service is included in the definition of practice of optometry under section 17401 of the Michigan Public Health Code, Act 368 of 1978, as amended, being § 333.17401 of the Michigan compiled laws, as of May 20, 1992.
(6) Suppliers of vision and prosthetic optical procedures shall use the appropriate procedure code V0000-V2999 listed in Medicare's National Level II
Codes as referenced in 418.10107 (2) to describe services provided.
(7) Payment shall be made for the following vision CPT codes: $50.00 for V2744, V2750, and V2760;
$25.00 for V2715; and $160.00 for V2020.
R 418.10209 Hearing services.
Rule 209. (1) A provider performing a comprehensive otorhinolaryngologic
evaluation shall report the service using the appropriate evaluation and management service.
(2) A provider shall not report an otoscope a rhinoscopy or a tuning fork
test in addition to a comprehensive ear evaluation or office visit.
(3) A provider performing special otorhinolaryngologic procedures, in addition to the evaluation, shall report those services using procedure codes 92507-92599.
(4) An audiologist and a speech therapist shall use procedure codes 92502-92599. An audiologist, a speech therapist, and a speech and hearing
center shall use procedure codes 92502-92599 and procedure codes V5030- V5240 for hearing aid services.
(5) Hearing aid suppliers shall use the appropriate procedure code
V5008-V5230 listed in Medicare's National Level II Codes as referenced in 418.10107(2) to describe services provided.
(6) When requesting payment for hearing aids a minimum of 2 comparable written quotations shall be required for hearing aids which exceed $1,500 per hearing aid, including related services such as orientation, fitting, ear molds, support, adjustment, conformity check, batteries, warranties and follow- up. Only a single price quotation shall be required for hearing aids, including related services, that cost
$1,500 or less per hearing aid.
R 418.101002a Conversion factor for practitioner services.
Rule 1002a. (1) The workers' compensation agency shall determine the conversion factor for medical, surgical, and radiology procedures. The conversion factor shall be used by the workers' compensation agency for determining the maximum allowable payment for medical, surgical, and radiology procedures. The maximum allowable payment shall be determined by multiplying the appropriate conversion factor times the relative value unit assigned to a procedure. The relative value units are listed for the medicine, surgical, and radiology procedure codes in a manual separate from these rules. The manual shall be published annually by the workers' compensation agency using codes adopted from "Physicians' Current Procedural Terminology (CPT®)" as referenced in R 418.10107 (a). The workers' compensation agency shall determine the relative values by using information found in the "Medicare RBRVS: The Physicians' Guide" as adopted by reference in R 418.10107 (c).
(2) The conversion factor for medicine, radiology, and surgical procedures shall be $46.72 for the year 2012 and shall be effective for dates of service on the effective date of these rules.
R 418.101003a Reimbursement for dispensed medications.
Rule 101003a. (1) Prescription medication shall be reimbursed at the average wholesale price (AWP) minus 10%, as determined by the Red Book, referenced in R 418.10107, plus a dispense fee. All of the following apply:
(a) The dispense fee for a brand name drug shall be $3.50 and shall be billed with WC700-B.
(b) The dispense fee for a generic drug shall be $5.50 and shall be billed with WC700-G.
(c) Reimbursement for repackaged pharmaceuticals shall be based on Red Book Online manufacturer’s AWP price of the product minus 10% plus a dispensing fee of $3.50 for brand name and $5.50 for generic.
(d) All pharmaceutical bills submitted for repackaged products shall include the original manufacturer or distributer stock package national drug code or NDC number.
(e) Dispensed repackaged generic products shall be reimbursed at the equivalent generic for payment.
(f) When a pharmaceutical is billed using an unlisted or “not otherwise specified code” and the charge exceeds $35.00, then the billing shall be under CPT code 99070.
(2) Over-the-counter drugs (OTC's), dispensed by a provider other than a pharmacy, shall be dispensed in 10-day quantities and shall be reimbursed at the average wholesale price, as determined by the Red Book, or $2.50, whichever is greater.
R 418.101207 Types of certification.
Rule 1207. (1) Certification shall be either unconditional or conditional.
(2) The workers’ compensation agency shall issue unconditional certification for a period of 3 years.
(3) The agency may issue conditional certification if it is determined that the carrier or other entity does not fully satisfy the criteria in R 418.101206(3). If the carrier or other entity agrees to undertake corrective action, then conditional certification shall be granted by the agency for a maximum period of 1 year.
(a) If the workers’ compensation agency receives multiple written complaints regarding a carrier, or the carrier's review process, and the agency determines the complaints are valid, or that the carrier has not processed payment for medical services in accord with these rules, then the agency may issue conditional certification.
(4) The workers’ compensation agency may at any time modify an unconditional certification to a conditional certification if the agency determines that the carrier or other entity fails to satisfy the criteria set forth in R 418.101206(3).
(5) The carrier shall have the right to appeal the certification decisions under the procedures in these rules.
(6) Failure to file Annual Report (WC406) or Professional Certification for Health Care Review Program (WC590) may result in denial or downgrading of the certification of a Health Care Review Program by the workers’ compensation agency.
R 418.101303 Provider's request for reconsideration of bill; carrier's response to provider's right to appeal.
Rule 1303. (1) Within 30 days of receipt of a provider’s request for reconsideration, the carrier shall notify the provider of the actions taken and provide a detailed statement of the reasons. The carrier’s notification shall include an explanation of the appeal process provided under these rules, including the fact that any requested administrative appeal hearing shall be conducted by a magistrate of the department of licensing and regulatory affairs.
(2) If a provider disagrees with the action taken by the carrier on the provider's request for reconsideration, then a provider may file an application for mediation or hearing with the department of licensing and regulatory affairs. A provider shall send its application for mediation or hearing to the agency within 30 days from the date of receipt of a carrier's denial of the provider's request for reconsideration. The provider shall send a copy of the application to the carrier.
(3) If, within 60 days of the provider's request for reconsideration, the provider does not receive payment for the adjusted or rejected bill or a portion of the bill, or a written detailed statement of the reasons for the actions taken by the carrier, then the provider may apply for mediation or hearing. The provider shall send the application for mediation or hearing to the agency and shall send a copy to the carrier.
