20 Miss. Code. R. 2-II - SCOPE

The Mississippi Workers' Compensation Medical Fee Schedule does the following:

A. Establishes rules/guidelines by which the employer shall furnish, or cause to be furnished, to an employee who suffers a bodily injury or occupational disease covered by the Mississippi Workers' Compensation Law, reasonable and necessary medical, surgical, and hospital services and medicines, supplies or other attendance or treatment as necessary. The employer shall provide to the injured employee such medical or dental surgery, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances which are reasonable and necessary to treat, cure, and/or relieve the employee from the effects of the injury/illness, in accordance with MCA § 71-3-15 (Rev. 2000), as amended.

B. Establishes a schedule of maximum allowable reimbursement (MAR) for such treatment, attendance, service, device, apparatus, or medicine.

C. Establishes rules/guidelines by which a health care provider shall be paid the lesser of (a) the provider's total billed charge, or (b) the maximum allowable reimbursement (MAR) established under this Fee Schedule.

D. Establishes rules for cost containment to include utilization review of health care and health care services, and provides for the acquisition by an employer/payer, other interested parties, and the MWCC, of the necessary records, medical bills, and other information concerning any health care or health care service under review.

E. Establishes rules for the evaluation of the appropriateness of both the level and quality of health care and health care services provided to injured employees, based upon medically accepted standards.

F. Authorizes employers/payers to withhold payment from, or recover payment from, health facilities or health care providers that have made excessive charges or which have provided unjustified and/or unnecessary treatment, hospitalization, or visits.

G. Provides for the review by the employer/payer or MWCC of any health facility or health care provider records and/or medical bills that have been determined not to be in compliance with the schedule of charges established herein.

H. Establishes that a health care provider or facility may be required by the employer/payer to explain in writing the medical necessity of health care or health care service that is not usually associated with, is longer and/or more frequent than, the health care or health care service usually accompanying the diagnosis or condition for which the patient is being treated.

I. Provides for medical cost containment review and decision responsibility. The rules and definitions hereunder are not intended to supersede or modify the Workers' Compensation Act, the administrative rules of the MWCC, or court decisions interpreting the Act or the MWCC's administrative rules.

J. Provides for the monitoring of employers/payers to determine their compliance with the criteria and standards established by this Fee Schedule.

K. Establishes deposition/witness fees.

L. Establishes fees for medical reports.

M. Provides for uniformity in billing of provider services.

N. Establishes rules/guidelines for billing.

O. Establishes rules/guidelines for reporting medical claims for service.

P. Establishes rules/guidelines for obtaining medical services by out-of-state providers.

Q. Establishes rules/guidelines for Utilization Review to include pre-certification, concurrent review, discharge planning and retrospective review.

R. Establishes rules for dispute resolution which includes an appeal process for determining disputes which arise under this Fee Schedule.

S. Establishes a peer review system for determining medical necessity. Peer review is conducted by professional practitioners of the same specialty as the treating medical provider on a particular case.

T. Establishes the list of health care professionals who are considered authorized providers to treat employees under the Mississippi Workers' Compensation Law; and who, by reference in this rule, will be subject to the rules, guidelines and maximum allowable reimbursement (MAR) in this Fee Schedule.

U. Establishes financial and other administrative penalties to be levied against payers or providers who fail to comply with the provisions of the Fee Schedule, including but not limited to interest charges for late billing or payment, percentage penalties for late billing or payment, and additional civil penalties for practices deemed unreasonable by the MWCC.

Notes

20 Miss. Code. R. 2-II

Amended 6/14/2017 Amended 6/15/2019