C.M.R. 90, 351, ch. 5, § 351-5-1, subsec. 351-5-1-07

Current through 2024-44, October 30, 2024

Subsection 351-5-1-07 - REIMBURSEMENT

1. The injured employee is not liable for payment of any medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39­A M.R.S.A. §206. Except as provided by 39­A M.R.S.A. §206(2)(B), health care providers may charge the patient directly only for the treatment of conditions that are unrelated to the compensable injury or disease. See 39­A M.R.S.A. §206(13).

2. Changes to bills by employers/insurers are not allowed. The employer/insurer must pay the health care provider's usual and customary charge or the maximum allowable payment under this chapter, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same health care provider or the underlying injury has been controverted or denied.

A. When there is a dispute whether the provision of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer shall pay the undisputed amounts, if any, and file a notice of controversy within 30 days of receipt. A copy of the notice of controversy must be sent to the health care provider from whom the bill originated in accordance with Chapter 3.

B. In cases where the underlying injury has been controverted or denied, a copy of the notice of controversy must be sent to each health care provider that submits or has submitted a request for payment within 30 days of receipt.

C. A health care provider, employee or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the provision of medical services.

3. When there is a dispute whether a request for future medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the Act, the employer/insurer must file a notice of controversy within 30 days of receipt of the request. A copy of the notice of controversy must be sent to the originator of the request. A health care provider, employee, or other interested party is entitled to file a petition for payment of medical and related services for determination of any dispute regarding the request for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids.

4. Payment of a medical bill is not an admission by the employer/insurer as to the reasonableness of subsequent medical bills.

5. Nothing in this chapter precludes payment agreements to promote the quality of care and/or the reduction of health care costs.

A. A written payment agreement directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available under this chapter.

B. A written payment agreement between a health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available under this chapter only if the employer/insurer is a contractual beneficiary of the payment agreement on the date of service.

C. An employee retains the right to select health care providers for the treatment of an injury or disease for which compensation is claimed regardless of any such payment agreement.

D. An employer/insurer that invokes a payment agreement to pay an amount that is different from the maximum allowable payment otherwise available under this chapter shall reference that payment agreement in the employer/insurer's explanation of payment or benefit.

E. In the event of a dispute as to whether there is a payment agreement that supersedes the maximum allowable payment otherwise payable, the burden is on the party invoking the payment agreement to provide a written contract between the provider and the network within 30 days of a provider's request. This contract must establish the party's right to pay an amount different than provided in this chapter. Failure to produce the contract within 30 days of a request will result in the bill being subject to the maximum allowable payment established in this chapter.

6. Payment to out-of-state health care providers who treat injured employees pursuant to 39­A M.R.S.A. §206 are subject to this chapter.

7. Modifiers which affect reimbursement are as follows:

-22 Increased Procedural Services: pay 150% of the maximum allowable payment under this chapter.

-50 Bilateral Procedure: pay 150% of the maximum allowable payment under this chapter for both procedures combined.

-51 Multiple Procedures: pay the highest weighted procedure at 100% of the maximum allowable payment under this chapter and all additional procedures at 50% of the maximum allowable payment under this chapter. Add-on codes are not subject to discounting.

-52 Reduced Services: pay 50% of the maximum allowable payment under this chapter if the procedure was discontinued after 1) the employee was prepared for the procedure and 2) the employee was taken to the room where the procedure was to be performed. Pay 100% of the maximum allowable payment if the procedure was discontinued after 1) the employee received anesthesia or 2) the procedure was started (e.g. scope inserted, intubation started, incision made).

-53 Discontinued Procedure: pay 25% of the maximum allowable payment under this chapter.

-54 Surgical Care Only: pay the intra-operative percentage of the maximum allowable payment under this chapter.

-55 Post-operative Management Only: pay the post-operative percentage of the maximum allowable payment under this chapter.

-56 Pre-operative Management Only: pay the pre-operative percentage of the maximum allowable payment under this chapter.

-59 Distinct Procedural Service: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-62 Two Surgeons: pay each surgeon 75% of the maximum allowable payment under this chapter.

-66 Surgical Team: pay 100% of the maximum allowable payment under this chapter for the surgical procedure and 25% of the maximum allowable payment under this chapter for the surgical procedure for each additional surgeon in the same specialty as the primary surgeon. If the surgeons are of two different specialties, each surgeon must be paid 100% of the maximum allowable payment under this chapter.

-73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: pay 50% of the maximum allowable payment under this chapter.

-80 Assistant Surgeon: pay 25% of the maximum allowable payment under this chapter.

-81 Minimum Assistant Surgeon: pay 10% of the maximum allowable payment under this chapter.

-82 Assistant Surgeon (when qualified resident surgeon not available): pay 25% of the maximum allowable payment under this chapter.

-AS Assistant Surgeon (physician assistant, nurse practitioner, or clinical nurse specialist): pay 25% of the maximum allowable payment under this chapter.

-AD Surgical Anesthesia: Physician medically supervised more than 2 to 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter.

-QK Surgical Anesthesia: Physician medically directed 2, 3, or 4 concurrent procedures: pay 50% of the maximum allowable payment under this chapter.

-QX Surgical Anesthesia: CRNA was medically directed by a physician (2, 3, or 4 concurrent procedures): pay 50% of the maximum allowable payment under this chapter.

-QY Surgical Anesthesia: Physician medically directed a CRNA in a single case: pay 50% of the maximum allowable payment under this chapter.

-XE Separate Encounter: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XP Separate Practitioner: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XS Separate Structure: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

-XU Unusual Non-Overlapping Service: pay 100% of the maximum allowable payment under this chapter (not subject to multiple procedure discounting).

C.M.R. 90, 351, ch. 5, § 351-5-1, subsec. 351-5-1-07