Florida Division of Workers’ Comp Medicare Reimbursement Manual Panel Meeting: November 20

Nov 24, 2008

The Florida Division of Workers’ Compensation Medicare Reimbursement Manual Panel met on Thursday, November 20, 2008 to consider testimony and comments regarding proposed Rule 69L-7.501 relating to Medicare’s Outpatient Prospective Payment System (“OPPS”).  If approved, this Rule would adopt OPPS in concert with determined payment adjustment factors as the methodology for reimbursing hospitals 60 and 75 percent of usual and customary charges for outpatient services provided to Florida’s injured workers.

A representative from the National Council on Compensation Insurance (“NCCI”) presented an analysis on the proposed medical fee reimbursement changes for hospital outpatient services.  These changes would revise the outpatient reimbursement schedule to be based on OPPS, rather than the current system of reimbursing a percentage of the hospital’s usual and customary charges (“UCC”).  Historically, UCCs have been interpreted to be defined as “billed charges,” meaning that each hospital is paid for outpatient services based on whatever rates it has established. 

Currently, reimbursement for outpatient services in Florida for workers’ compensation injuries depends on the category of service:

  • Category 1:  Any scheduled outpatient radiology or clinical laboratory services that are not performed in conjunction with a scheduled surgery shall be reimbursed by the schedule of maximum reimbursement allowance (“MRA”) listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual (“FWCRM”), 2007 Edition. In addition, any outpatient physical, occupational, and speech therapy is reimbursable by the listed MRA in the FWCRM.
  • Category 2:  The reimbursement level for scheduled outpatient surgeries is 60 percent of UCC. In addition, any scheduled radiology and clinical laboratory services performed in conjunction with, as defined as being performed on the day of or up to three days before a scheduled surgery, are also reimbursed at 60 percent of UCC.
  • Category 3:  All other outpatient procedures should be reimbursed at 75 percent of UCC.

Proposed changes would revise the outpatient schedule to be based on OPPS:

  • Category 1:  No changes
  • Category 2:  Reimbursement of these services at a maximum of 173.64 percent of Medicare OPPS
  • Category 3:  Reimbursement of these services at a maximum of 394.79 percent of Medicare OPPS

NCCI estimates that implementing Medicare multipliers of 1.7364 for Category 2 procedures and 3.9479 for Category 3 procedures would result in an overall cost impact on the Florida workers’ compensation system of between -0.1 and +0.4 percent (-$4.8 to $19.2M million).

If the proposed Rule changes were enacted in its current form, NCCI anticipates that the overall impact could be premium neutral.

To view the complete NCCI analysis, click here.

The meeting was then adjourned.


Should you have any questions or comments, please do not hesitate to contact Colodny Fass.


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