Subpart 1.
Excessive health care
provider charges.
A billing charge for services, articles, or supplies provided
to an employee with a compensable injury is excessive if any of the conditions
in items A to I apply to the charge. A payer is not liable for a charge which
meets any of these conditions.
A. the
charge wholly or partially duplicates another charge for the same service,
article, or supply, such that the charge has been paid or will be paid in
response to another billing; or
B.
the charge exceeds the provider's current usual and customary charge, as
specified in subpart 2, item B, for the same or similar service, article, or
supply in cases unrelated to workers' compensation injuries; or
C. the charge is described by a billing code
that does not accurately reflect the actual service provided; or
D. the service does not comply with the
treatment standards and requirements adopted under Minnesota Statutes, section
176.83, subdivision 5,
concerning the reasonableness and necessity, quality, coordination, level,
duration, frequency, and cost of services; or
E. the service was performed by a provider
prohibited from receiving reimbursement under Minnesota Statutes, chapter 176,
pursuant to Minnesota Statutes, sections
176.83,
176.103,
176.1351, and
256B.0644;
or
F. the service, article, or
supply is not usual, customary, and reasonably required for the cure or relief
of the effects of a compensable injury or is provided at a level, duration, or
frequency that is excessive, based on accepted medical standards for quality
health care and accepted rehabilitation standards under Minnesota Statutes,
section
176.136,
subdivision 2, clause (2); or
G.
the service, article, or supply was delivered in violation of the federal
Medicare anti-kickback statutes and regulations as specified in part 5221.0700,
subpart 1a; or
H. where approval
for a change of doctor is required by part 5221.0430 for the provider
submitting the charge, and approval has not been obtained from the payer,
commissioner, or compensation judge; or
I. the service is outside the scope of
practice of the particular provider or is not generally recognized within the
particular profession of the provider as of therapeutic value for the specific
injury or condition, under Minnesota Statutes, section
176.136,
subdivision 2, clause (3).
Subp.
2.
Limitation of payer liability.
A payer is not liable for health care charges which are
excessive under subpart 1. If the charges are not excessive under subpart 1, a
payer's liability for payment of charges is limited as provided in items A to
F.
A. If the medical fee schedule
applies to the service according to part 5221.4005, subpart 3, the payer's
liability shall be limited to the maximum amount allowed for any service,
article, or supply in the medical fee schedule in effect on the date of the
service, or the provider's usual and customary fee, whichever is
lower.
B. Except as provided in
items C to F, if the maximum fee for service, article, or supply is not limited
by parts 5221.4005 to 5221.4070, the payer's liability for payment shall be
limited to 85 percent of the provider's usual and customary charge, or 85
percent of the prevailing charge for similar treatment, articles, or supplies
furnished to an injured person when paid for by the injured person, whichever
is lower.
(1) A usual and customary charge
under Minnesota Statutes, section
176.136,
subdivision 1b, paragraphs (a) and (b), means the amount actually billed by the
health care provider to all payers for the same service, whether under workers'
compensation or not, and regardless of the amount actually reimbursed under a
contract or government payment system.
(2) A prevailing charge under Minnesota
Statutes, section
176.136,
subdivision 1b, paragraph (b), is the 75th percentile of the usual and
customary charges as defined in subitem (1) , based on no more than two years
of billing data immediately preceding the date of service, for each service,
article, or supply if the database for the service meets all of the following
criteria:
(a) the database includes only
Minnesota providers, with at least three different, identifiable providers of
the same provider type, distinguished by whether the service is an inpatient
hospital service, or an outpatient physician, pathology, laboratory,
chiropractic, physical therapy or occupational therapy service, or provider of
other similar service, article, or supply;
(b) there are at least 20 billings for the
service, article, or supply; and
(c) the standard deviation is less than or
equal to 50 percent of the mean of the billings for each service in the data
base or the value of the 75th percentile is not greater than or equal to three
times the value of the 25th percentile of the billings.
C. Payment for services, articles,
and supplies provided to an employee while an outpatient at a hospital shall be
as provided in parts 5221.4005 to 5221.4070, except as provided in Minnesota
Statutes, section
176.136,
subdivision 1b. The payer's liability for services provided by a nursing home
that participates in the medical assistance program shall be the rate
established by the commissioner of human services.
D. Payment for services, articles, and
supplies provided to an employee who is an inpatient at a hospital shall be as
provided in Minnesota Statutes, sections
176.136,
subdivision 1b, and 176.1362.
E.
Charges for cost of copies of medical records and postage are governed by parts
5219.0100 to 5219.0300 and are not subject to the 85 percent reimbursement
limit specified in item B. Travel expenses incurred by an employee for
compensable medical services shall be paid at the rate equal to the rate paid
by the employer for ordinary business travel expenses, or the rate paid by the
state of Minnesota under the commissioner's plan for employment-related travel,
whichever is lower. Reimbursement for employee travel expenses is not subject
to the 85 percent reimbursement limit specified in item B.
F. Charges for supplementary reports that are
not required reports under part 5221.0410, subpart 7, and charges for return to
work services under part 5221.0420, subpart 3, are not subject to the 85
percent reimbursement limit specified in item B.
Subp. 3.
Collection of excessive
charges.
A provider may not collect or attempt to collect payment from
an injured employee, or any other source, charges for a compensable injury
which the payer has determined are excessive under subpart 1 or which exceed
the maximum amount payable specified in subpart 2, unless payment is ordered by
the commissioner, compensation judge, or Workers' Compensation Court of
Appeals. Unless the provider or the employee has filed a claim for a
determination of the amount payable with the commissioner, the health care
provider must remove the charges from the billing statement. If a dispute
exists as to whether an employee's injury is compensable under Minnesota
Statutes, chapter 176, and the employee has general health insurance, payment
of medical bills is governed by Minnesota Statutes, section
176.191,
subdivision 3.
