Frequently Asked Questions

REFERENCES:
Title 19 Del C. §2322B
Procedures and Requirements for Promulgation of Health Care Payment System

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

  1. Why do some codes have fees set for them and others don't? What does POC85 mean?
  2. What is a geozip?
  3. What is a modifier?
  4. Where can I find the "Correct Coding Policy Manual?"
  5. Where can I find the "Payment Guide to Global Days?"
  6. How and when are the fees adjusted each year? Where can I find the indicators used to adjust the fees - Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics (the "fee schedule") ,as well as the Consumer Price Index-Urban, U.S. City Average, Medical (ASTCs and Hospitals)?
    1. General Information
    2. Anesthesia Methodology - Effective 09/11/2013
    3. Revenue Neutral Special Instructions - Effective 09/11/2013
    4. 01/14/2014 Fee Schedule Update - Special Instructions
    5. 09/11/2013 Fee Schedule Update - Special Instructions
    6. 01/11/2013 Fee Schedule Update - Special Instructions
    7. Prior Fee Schedule Updates - Special Instructions
  7. How are HCPCS codes reimbursed?
  8. Did the OWC adopt the new MS-DRGs?
  9. Does the fee schedule apply to medical treatments before May 23, 2008?
  10. Are emergency services exempt from the HCPS and fee schedule?
  11. Does the Delaware fee schedule address missed appointments?
  12. Should we pay medical bills according to our contract or the fee schedule?
  13. How do I reimburse for an out-of-state treatment?
  14. How do you reimburse for the pharmaceutical drugs and/or drugs listed on the OWC Preferred Drug List?
  15. What is the dispensing fee for pharmaceutical drugs?

REFERENCES:
Title 19 Del C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

  1. Is balance billing allowed?
  2. How do I pay bills where there are professional and technical components (PC/TC)?
  3. Should a medical provider send bills to the employer or the payer?
  4. What can I do if the payer won't pay me correctly?
  5. Is the interest on medical bills owed if the claim is disputed for valid reasons but later determined to be compensable?
  6. Must bills be submitted on certain forms?
  7. Can you tell me if I am calculating a bill correctly?
  8. How should the payer handle a bill with incorrect codes? Can the payer alter the codes on a bill? Does the fee schedule allow for down-coding?
  9. When an ambulance travels from one geozip to another, which one should count for billing?
  10. How do we reimburse assistant surgeons?
  11. How do we handle bilateral/multiple procedures?
  12. How should providers bill for exposure surgeons as indicated in 7.6 DE Admin code 1342 of the low back practice guidelines?

REFERENCES:
Title 19 Del C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 5.0
Utilization Review

  1. How would a utilization review (UR) provider become eligible to perform utilization review for the Delaware Workers' Compensation Health Care Payment System?
  2. How does the law on utilization review affect the process at the OWC?
  3. What date should be used to begin counting the number of occurrences when determining a Utilization Review (UR)?
  4. What is the deadline for processing a Utilization Review (UR) request?
  5. Why is it important to specify each treatment modality(s) for review on the "Request for Utilization Review" form (item 8 on the form) versus using the blanket statement "any and all treatment?"
  6. How much does a Utilization Review (UR) cost? NOTE: UR fees increased August 1, 2010.
  7. I have been treating a patient for ongoing pain after a work injury. The case is well over 6 months old, so care falls under the chronic guideline. My treatment has been helping the patient continue to work, however, further care is being denied as "the number of treatments provided" exceeds the guidelines. The documentation shows my care is helping the patient, and is keeping them working. If I don't provide the care, the patient will get worse. What are my options?
  8. What are the injured workers' options if a carrier will not pre-authorize a health care service and/or treatment (e.g. surgery), and the certified health care provider will not perform the treatment and/or health care service without a preauthorization?
  9. What is the "peer-to-peer conversation" as part of the utilization review process?

REFERENCES:
Title 19 Del. C. §2322D
Certification of health care providers.

19 DE Admin. Code 1341 - Section 3.0
Health Care Provider Certification

  1. Who has to become certified to treat injured workers?
  2. Does the DOL issue certification numbers to certified providers?

REFERENCES:
Title 19 Del. C. §2322E
Certification of health care providers.

19 DE Admin. Code 1341 - Section 6.0
Forms

  1. What CPT code should providers use for the physician's report (provider form) and what is the fee? When should physicians fill out the form?
  2. When should I fill out the provider or employer forms?

MISCELLANNEOUS

  1. How does HIPAA affect workers' compensation?
  2. Are any injured workers exempt from coverage under the Delaware Workers' Compensation Act?
  3. Where can I find a list of the 7/6/09 changes to Title 19 Del.C. §2322?
  4. What are the effective dates for each of the Delaware workers' compensation health care practice guidelines?

REFERENCES:
Title 19 Del C. §2322B
Procedures and Requirements for Promulgation of Health Care Payment System

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

1. Why do some codes have fees set for them and others don't? What does POC85 mean?

Excluding those exceptions mandated in the Delaware Code plus CPT Code 99080 (used for the physicians form), the fee schedule was populated with an actual fee dollar amount based on a certain threshold of occurrences for the CPT and HCPCS codes. When the data did not contain enough occurrences to determine a fee, the fee was set at 85% (85POC) of the actual charge. Effective 9/11/13 and wherever possible, CMS Relative Value units and conversion factors derived from Delaware workers' compensation data were used in the itemized fee schedule to significantly reduce the number of fees paid at 85POC, pursuant to the following 19 Del. C. §2322B3(b),

  • b. On a 1-time basis in 2013, with respect to all possible procedures, treatments, and services for which there was insufficiently reliable data prior to 2013 for the Health Care Advisory Panel to determine a payment based upon the formula described above, the Health Care Advisory Panel shall use a formula based upon relative value units as determined by the Centers for Medicare and Medicaid Services to determine fees for said procedures, treatments, and services. Those fees shall then be subject to the adjustments described in paragraphs (3)d. and e. of this section in subsequent years.

Pursuant to 19 DE Admin Code 1341 ("the regulations"):

  • 4.4.1 The maximum allowable payment for health care treatment and procedures shall be the lesser of the health care provider's actual charges or ninety percent (90%) of the 75th percentile of actual charges within the geozip where the service or treatment is rendered, utilizing information contained in employers' and insurance carriers' national databases. If an employer or insurance carrier contracts with a provider for the purpose of providing services under the Act, the rate negotiated in such contract shall prevail.
  • 4.4.2 Whenever the health care payment system does not set a specific fee for a procedure, treatment or service in the schedule, the amount of reimbursement shall be eighty-five percent (85%) of actual charge ("POC 85").

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2. What is a geozip?

Purusant to Title 19 Del. C. §2322B(3)(a),

  • a. The maximum allowable payment for health care treatment and procedures covered under this chapter shall be the lesser of the health care provider's actual charges or the fee set by the payment system. The payment system will set fees at 90% of the seventy-fifth percentile of actual charges within the geozip where the service or treatment is rendered, utilizing information contained in employers' and insurer carriers' national databases. For pathology, laboratory, and radiological services and durable medical equipment, the payment system will set fees at 85% of 90% of the 75th percentile of actual charges. For purposes of this section, "geozip" means an area defined by reference to United States ZIP Codes; Delaware shall consist of 1 "197 geozip" (comprised of all areas within the State where the address has a ZIP Code beginning with the 3 digits "197" or "198"), and 1 "199 geozip" (comprised of all areas within the State where the address has a ZIP Code beginning with the 3 digits of "199"). If a geozip does not have the necessary number of charges and fees to calculate a valid percentile for a specific procedure, treatment, or service, the Health Care Advisory Panel in its discretion may combine data from Delaware's 2 geozips for a specific procedure, treatment, or service. Those fees shall then be subject to the adjustments described in paragraphs (3)d. and e. of this section in subsequent years.

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3. What is a modifier?

Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code. If more than one modifier is needed, place modifier 99 after the procedure code to indicate that two or more modifiers will follow. Some modifier descriptions in this fee schedule have been changed from the CPT language.

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4. Where can I find the "Correct Coding Policy Manual?"

The OWC adopted the National Correct Coding Initiative as the review standard for bundling edits, pursuant to 19 Del.C. §2322B(10)(c) as follows:

  • c. The health care payment system shall require that services be reported with the Healthcare Common Procedural Coding System Level II ("HCPCS Level II") or CPT codes that most comprehensively describe the services performed. Proprietary bundling edits more restrictive than the National Correct Coding Policy Manual in Comprehensive Code Sequence for Part B Medicare Carriers, Version 12.0, U.S. Department of Health and Human Services, Centers for Medicare and Medicare Services, 7500 Security Boulevard, Baltimore, Maryland, 21244, shall be prohibited. Bundling edits is the process of reporting codes so that they most comprehensively describe the services performed.

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5. Where can I find the "Payment Guide to Global Days?"

You may find follow-up days (FUDS) listed as a column in the itemized fee schedule, as of 11/2009. In addition, section 4.1.5 of the fee schedule instructions and guidelines cites the source used.

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6. How and when are the fees adjusted each year? Where can I find the indicators used to adjust the fees - Consumer Price Index -- Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics (the professional services "fee schedule") ,as well as the Consumer Price Index-Urban, U.S. City Average, Medical (ASCs and Hospitals)?

6a. General Instructions

Effective July 6, 2009, and pursuant to Title 19 Del. C. §2322B(14), "One year after the effective date of the regulation and each January thereafter, the DOL shall make an automatic adjustment to the maximum payment for a procedure, treatment, or service in January of that year." Effective August 7, 2012, 19 Del. C. §§2322B(8) and (9) changed the Hospital and Ambulatory Surgery Center fee methodologies. Effective 6/27/13, the annual hospital update changed to a comparison in the change to the CPI-Urban, U.S. City Average, to mirror the index used for professional health care services.

Health Care Treatment and Procedures
Pursuant to Title 19 Del. C. §2322B(3), "The payment system will be adjusted yearly based on percentage changes to the CPI-Urban, U.S. City Average, All Items.

Ambulatory Service Treatment Centers (ASCs)
Title 19 Del. C. §2322B(9) requires ASC's to submit a report to the DE Dept. of Labor (Office of Workers' Compensation - 4425 N. Market St., 3rd Floor, Wilmington, DE 19802) via each ASC's Certified Public Accountant (CPA) or Independent Financial Auditor (IFA) by October 31st each year. Each report must reflect one overall rate change for that individual ASC's prior fiscal year. The Department of Labor's independent "financial advisor" will verify the reports and calculate each ASCs new percent of charge (POC) based on a comparison of the reported overall rate change to the change in the Consumer Price Index-Urban, U.S. City Average for Medical Care.

Hospital Fees
Pursuant to Title 19 Del. C. §2322B(8)(b) requires a Hospital's Certified Public Accountants (CPA) or Independent Financial Auditors (IFA) to submit reports to the Delaware Health Care Association (DHA) by October 31st each year. The DHA compiles a rate change report as specified in the statute via its CPA or IFA to the DE Dept. of Labor (Office of Workers' Compensation - 4425 N. Market St., 3rd Floor, Wilmington, DE 19802). The Department of Labor's independent "financial advisor" will verify the report and calculate one new percent of charge (POC) for the collective hospitals based on a comparison of the reported overall rate change to the change in the Consumer Price Index-Urban, U.S. City Average. You can find CPI information at the Bureau of Labor Statistics webpage: http://data.bls.gov/cgi-bin/surveymost?cu

Professional Services Fees

For the professional services "fee schedule" you will need to check the first box that reads, "U.S. All items, 1982-84=100 - CUUR0000SA0."

The July 6, 2009 law change allowed the DOL to update the fee schedule data at the same time the CPT and HCPCS codes become effective. This change consolidated the two previously separate updates - November (fees) and January (codes) - into one January (fees and codes) update. Now that the fee schedule update occurs in January, the DOL may include the most recent year's percent change in the U.S. DOL Consumer Price Index (CPI) versus calculating the fee schedule on a lag.

6b. Anesthesia Methodology - Effective 09/11/2013

Anesthesia is paid pursuant to 19 DE Admin Code 1341, Section 4.20, which is available at http://dowc.ingenix.com/info.asp?page=rules#420. Use CMS base units, which are available to download at http://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html.

6c. Revenue Neutral Special Instructions - Effective 09/11/2013

Revenue Neutral

Although fees will not increase until January 31, 2016, some fees may change to keep medical coding updates revenue neutral, pursuant to 19 DE Admin Code 1341, Section 4.3.3.

Pursuant to 19 DE Admin Code 1341, Section 4.3.3

  • 4.3.3 For codes that are deleted and bundled, the remaining/new code will be adjusted to reflect the value of the previously unbundled/deleted codes, so the charge is revenue neutral. For entire procedures that are bundled into a new code, the new code will include the value of the previously segregated codes. The Department of Labor will publish to its web site additional special instructions associated with the revenue neutral fee conversion, where applicable. Once revenue neutral fees are established, they will adjust with the annual CPI-U adjustment referenced in 19 Del. C. §2322(3).

Special Revenue Neutral Instructions for Applicable CPT Codes

EFFECTIVE 09/11/2013:

In 2012, CPT codes 95885 and 95886 were added. With the 9/11/13 fee schedule update these two codes now bundle codes (95860, 95861, 95863, 95864, and 96870) previously billed using separate fees. Effective 9/11/13, the CPT codes 95885 and 95886 in the itemized fee schedule only reflect the fees for one (1) extremity. The following table gives the revenue neutral fees for all the extremities.

CPT Code 95885 CPT code 95886
Number of Extremities Fee - geozip 197/198 Fee - geozip 199 Number of Extremities Fee - geozip 197/198 Fee - geozip 199
1 $228.69 $73.20 1 $354.99 $207.64
2 $268.27 $115.55 2 $416.43 $327.78
3 $315.91 $172.88 3 $490.38 $490.38
4 $316.86 $147.95 4 $491.86 $419.67

Also keep in mind, 19 Del. C. §2322B(3)(a) mandates the following:

"The maximum allowable payment for health care treatment and procedures covered under this chapter shall be the lesser of the health care provider's actual charges or the fee set by the payment system."

6d. 01/ 31/2014 Fee Schedule Update - Special Instructions

NOTE: Pursuant to 19 Del. C. §2322B and effective 6/27/13, the statute includes a provision that freezes all fee increases until January 1, 2016.

Hospitals

Effective with the August 7, 2012, statutory change to 19 Del. C. §2322B(8), hospital fees are updated through a change in one overall percent of charge (POC). Hospitals bill their actual fee and then payers pay the fee for all hospitals based on the one POC for that year. For instance, if a CPT code is billed at $100, then the hospital is paid $75.63 in 2013. Effective on 1/31/2014, the percent of charge (POC) for hospitals is 75.63%.

The Delaware Healthcare Association submitted its rate change report on behalf of the following hospitals:

  1. Bayhealth Medical Center
  2. Beebe Medical Center
  3. Christiana Care Health System
  4. Nanticoke Health Services
  5. St. Francis Health Services

Ambulatory Surgery Centers (ASCs)

Effective with the August 7, 2012, statutory change to 19 Del. C. §2322B(9), ASC fees are updated through a change in each ASC's percent of charge, which makes them unique to each ASC. Effective 06/27/13, 19 Del. C. §2322B(9) contains a fee freeze until January 1, 2016. During the fee freeze, the ASCs' prior fiscal year rate change will be compared to a zero percent increase/decrease. The Office of Workers' Compensation will publish the new POC rates in this frequently asked question #6 under the appropriate year. For instance, if the 2014 percent of charge for ASC "A" is 88.70%, and the ASC bills a CPT code at $100, then the ASC is paid $88.70.

The following includes the 2014 percent of charge (POC) information for ASCs:

Name of Ambulatory Surgery Center: 2014 Percent of Charge
Cedar Tree Medical Center 85.00%
Christiana Spine Ambulatory Surgery Center
88.70%
Dover Surgicenter, LLC
(Rate change report received 02/04/2014)
88.70%
Delaware Surgery Center, LLC 88.70%
First State Surgery Center, LLC 63.90%
Glasgow Medical Center, LLC 85.60%
Lewes Surgery Center 73.13%
Limestone Medical Center, Inc. 80.81%
Minimally Invasive Surgical Neuroscience Center, LLC 88.70%
Orthopaedic Specialists Surgi-Center, LLC 88.70%
Outpatient Procedure Centers, LLC
(Added 03/24/2014)
85.00%
Spine Care Delaware, LLC 88.70%
Surgery Centers of Delmarva, LLC
(Rate change report received 02/12/14)
82.47%
Upper Bay Surgery Center, LLC
(Added 09/24/2014)
85.00%

6e. 09/11/2013 Fee Schedule Update - Special Instructions

NOTE: Pursuant to 19 Del. C. §2322B and effective 6/27/13, the statute includes a provision that freezes all fee increases until January 1, 2016.

This special fee schedule update reflects significant statute and regulatory changes, which stem from the passing of House Bill #175.

  • HB175 may be accessed at http://legis.delaware.gov - from the left side menu select GA147, HB, 175.
  • The regulatory changes are specifically identified in the September 2013 publication of the Register of Regulations, which is available at http://regulations.delaware.gov/services/register.shtml. If you access the information after September 2013, select the "previous" versus "current" link and then choose one of the downloads for the September 2013 Register.

Effective with this change, the CPT, HCPCS, and NCCI edits are updated to 2013 and will be updated each January 31 to reflect the current version, pursuant to 19 Del. C. §2322B(10).

Hospitals and ambulatory surgery centers (ASCs) will continue to use the same percent of charge indicated in the "January 2013 Fee Schedule Updates" section of this FAQ and must still submit annual rate change reports to the Department of Labor, pursuant to 19 Del. C. §§2322B(8)(a) and (9)(a).

6f. 01/31/2013 Fee Schedule Update - Special Instructions

NOTE: The medical codes are not updated in 2013. Continue to use the medical codes and bundling guidelines used in 2011.

Hospitals
Effective with the August 7, 2012, statutory change to 19 Del. C. §2322B(8), hospital fees are updated through a change in one overall percent of charge (POC). Hospitals bill their actual fee and then payers pay the fee for all hospitals based on the one POC for that year. For instance, if a CPT code is billed at $100, then the hospital is paid $79.36 in 2013. Effective on 1/31/2013, the percent of charge (POC) for hospitals is 79.36%

The Delaware Healthcare Association submitted its rate change report on behalf of the following hospitals:

  1. Bayhealth Medical Center
  2. Beebe Medical Center
  3. Christiana Care Health System
  4. Nanticoke Health Services
  5. St. Francis Health Services

Ambulatory Surgery Centers (ASCs)
Effective with the August 7, 2012, statutory change to 19 Del. C. §2322B(9), ASC fees are updated through a change in each ASC's percent of charge. In 2013, payers will apply a unique percent of charge (POC) to fees submitted by each ASC. The Office of Workers' Compensation will publish the new POC rates in this frequently asked question #6 under the appropriate year. For instance, if the 2013 percent of charge for ASC "A" is 88.70%, and the ASC bills a CPT code at $100, then the ASC is paid $88.70.

The following includes the 2013 percent of charge (POC) information for ASCs:

Name of Ambulatory Surgery Center: 2013 Percent of Charge
Christiana Spine Ambulatory Surgery Center
(Rate Change Report received 6/14/2013)
88.70%
Delaware Surgery Center, LLC 88.70%
Dover Surgicenter, LLC 88.70%
First State Surgery Center, LLC 83.90%
Glasgow Medical Center, LLC 88.20%
Lewes Surgery Center (Rate Change Report received 4/25/2013) 80.31%
Limestone Medical Center, Inc.
(Corrected report received 2/5/2013)
84.27%
Minimally Invasive Surgical Neuroscience Center, LLC
(Rate Change Report received 9/17/2013)
88.70%
Orthopaedic Specialists Surgi-Center, LLC 88.70%
Spine Care Delaware, LLC 88.70%
Surgery Centers of Delmarva, LLC 92.71%

6g. 2012 and Prior Fee Schedule Updates - Special Instructions

2012 Fee Schedule Updates

NOTE: The medical codes will not be updated in 2012. Continue to use the medical codes and bundling guidelines used in 2011.

The 2010-2011 CPI% changes for the January 31, 2012 fee updates were +3.2% for "All items" (professional services - the "fee schedule") and +3% for "Medical Care" (ASCs and Hospitals). You may find the CPI percentage change source information at the following link: 2010-2011: US DOL CPI Percent Change 2010-2011.pdf

2011 Fee Schedule Updates

The 2009-2010 CPI% changes for the January 31, 2011 fee updates were +1.6% for "All items" (professional services - the "fee schedule") and +3.4% for "Medical Care" (ASCs and Hospitals). You may find the CPO percentage change source information at the following link: 2009-2010: US DOL CPI Percent Change 2009-2010.pdf

2006-2010 Fee Schedule Updates

The 2007-2009 update to the fee schedule, effective January 29, 2010, included the change in the CPI % for 2007-2008 (+3.8% for "All Items;" +3.7% for "Medical Care"); and 2008-2009 (-0.4% for "All Items;" +3.2% for "Medical Care"). This update incorporated a one- time "catch-up" for fees tied to the change in the CPI - professional services (the "fee schedule"), hospitals, and ambulatory surgery centers (ASCs). The DOL calculated first the 2007-2008 change, then the 2008-2009 change in order to determine the final fee in the January 2010 fee schedule update. You may find the CPI percentage change source information at the links below:

2007-2008: http://www.bls.gov/cpi/cpid08av.pdf

2008-2009: US DOL CPI Percent Change Calculation 2008-2009

NOTE: The methodology used to update the January 2010 professional fee schedule data is the same methodology hospitals and ASCs would use when applying their respective CPI % change to 2009 fees. The example below shows the methodology to update the January 2010 fee from a 2009 hospital or ASC fee of $100.

STEP 1:
2007-2008 CPI Medical change = 3.7%
$100 x (100% + 3.7%) = $103.70

STEP 2:
2008-2009 CPI Medical change = 3.2%
$103.70 x (100% + 3.2%) = $107.02

FINAL RESULT
$100 fee in 2009 is now $107.02 in 2010 for ASTCs and Hospitals.

The 2006-2007 CPI % changes for the November 14, 2008, (1 year after the implementation date) fee updates were +2.8% for "All items" (the professional services "fee schedule") and +4.4% for "Medical Care" (ASCs and hospitals). You may find the CPI percentage change source information at the following link: http://www.bls.gov/cpi/cpid07av.pdf

The 2005-2006 CPI % changes for the November 14, 2007, (prior to the implementation date) fee updates were +3.2% for "All items" (the professional services "fee schedule"- already included at implementation date) and +4.0% for "Medical Care" (ASCs and Hospitals). You may find the CPI percentage change source information at the following link: http://www.bls.gov/cpi/cpid06av.pdf

7. How are HCPCS codes reimbursed?

Users can find HCPCS reimbursement amounts in the fee schedule.

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8. Did the OWC adopt the new MS-DRGs?

No. In the interest of facilitating transactions, we do encourage providers to use DRGs

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9. Does the fee schedule apply to medical treatments before May 23, 2008?

No. The schedule only applies to treatments covered under the Act and provided on or after May 23, 2008. The date of injury is not relevant.

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10. Are emergency services exempt from the HCPS and fee schedule?

Effective August 7, 2012, hospital only fees are no longer exempt from the hospital fee schedule.

Pursuant to Title 19 Del.C. §2322B(8)(b), "Healthcare provider services provided in an emergency department of a hospital, or any other facility subject to the Federal Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, and any emergency medical services provided in a prehospital setting by ambulance attendants and/or paramedics, shall be exempt from the healthcare payment system and shall not be subject to the requirement that a healthcare provider be certified pursuant to § 2322D of this title, requirements for preauthorization of services, or the healthcare practice guidelines adopted pursuant to § 2322C of this title."

Although emergency services are exempt from the HCPS, you will still find "emergency" codes listed in the fee schedule data for two reasons:

  1. The data is a compilation of Delaware health care fees that reached a specific threshold of occurrences. Any items in the raw data that occurred over the specified threshold were included in the published fee schedule.
  2. Non-emergency facilities also use those codes when they render that type of treatment. Non-emergency facilities that provide those types of treatment services will need to use those codes.

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11. Does the Delaware fee schedule address missed appointments?

No. The fee schedule only applies to services actually rendered in the treatment of an injured worker.

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12. Should we pay medical bills according to our contract or the fee schedule?

Pursuant to Title 19 Del.C. §2322B(4), "If an employer or insurance carrier contracts with a provider for the purpose of providing services under this chapter, the rate negotiated in any such contract shall prevail."

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13. How do I reimburse for an out-of-state treatment?

Pursuant to Title 19 Del.C. § 2322B(6):

(6) Procedures and requirements for promulgation of health care payment system. -- The health care payment system shall include provisions for health care treatment and procedures performed outside of the State of Delaware. If any procedure, treatment or service is rendered by a health care provider, hospital or ambulatory surgery center, who is licensed or permitted to render such procedure, treatment or service within the State of Delaware, but performs such procedure, treatment or service outside of the State of Delaware, the amount of reimbursement shall be the amount as set forth in the health care payment system. In the event that a procedure, treatment or service is rendered outside the State of Delaware by a health care provider, hospital or ambulatory surgery center, not licensed or permitted to render such procedure, treatment or service within the State of Delaware, the amount of reimbursement shall be the greater of:

  1. The amount set forth in the workers' compensation health care payment system or a fee schedule adopted by the state in which the procedure, treatment or service is rendered, if such a schedule has been adopted; or
  2. The amount that would be authorized by the payment system adopted pursuant to this chapter if the service or treatment were performed in the geozip where the injury occurred or where the employee was principally assigned.

Charges for a procedure, treatment or service outside the State of Delaware shall be subject to the instructions, treatment guidelines, and payment guides and policies in the health care payment system.

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14. How do you reimburse for the pharmaceutical drugs and/or drugs listed on the OWC Preferred Drug List?

Effective 9/11/13, significant revisions occurred in the pharmacy fee regulations to support the statutory changes mandated in HB175. Pursuant to 19 DE Admin Code 1341, Section 4.13 (http://dowc.ingenix.com/info.asp?page=rules) , the revised pharmacy regulation includes a new percent of AWP applied to the specified drug pricing indices; guidelines for physicians dispensing from their office; caps on fees for compounded and repackaged drugs; a new drug formulary, as well as a "Justification for Use of Non-Preferred Medication" form to obtain prior authorization for drugs identified as non-preferred; and protocols for prescribing brand name prescriptions. Click on the link above to access the current regulations. The left side menu of the web page includes links to the new drug formulary and the justification form (click on "Forms").

Medications that do not fall within the categories listed in the new drug formulary should be prescribed and dispensed in their generic form, pursuant to the caveats described in Section 4.13 and per the workers' compensation health care practice guidelines.

Effective 2/11/2014, Medi-Span became the sole source provider for pharmacy AWP. We are unable to publish the AWP reimbursement rates on this website. We suggest obtaining the AWP info from your insurance carriers or providers. The Medi-Span Master Drug Data Base (MDDB) or Drug Topics database is also available for purchase through the following web sites:

Medispan
http://www.medispan.com/marketing/ContentPage.aspx?contentId=9645d75e-f0b8-4db0-bca3-fb0339f0030a

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15. What is the dispensing fee for pharmaceutical drugs?

Pursuant to 19 DE Admin Code 1341, Section 4.13.1, the dispensing fee for generic drugs is $5.00 and for brand name drugs is $4.00. Physicians dispensing drugs from their office do not receive a dispensing fee.

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REFERENCES:
Title 19 Del.C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines


16. Is balance billing allowed?

Pursuant to Title 19 Del. C. §2322F(l), a provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

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17. How do I pay bills where there are professional and technical components (PC/TC)?

Fees for total, professional, and/or technical reimbursement components may appear in the Professional Services fee schedule in the areas of surgery, radiology, pathology and laboratory, and medicine.

When you receive a bill from a healthcare provider with no modifier, you can assume that the charge is for the total component, and pay the fee schedule amount for the "total component." If POC85 appears, pay 85% of the charged amount.

When you receive a bill with the modifier "PC" or "26," the charge is for the professional component and is paid at the amount listed for the "professional component." If POC85 appears, pay 85% of the charged amount.

When you receive a bill with the modifier "TC," this indicates the charge is for the technical component of the service and is paid at the amount listed for the "technical component." If POC85 appears, pay 85% of the charged amount.

When combined, the TC/PC splits should equal the fee schedule (actual number or 85POC, whichever is appropriate) for the total component.

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18. Should a medical provider send bills to the employer or the payer?

Send bills to the employer (if not insured) or insurance carrier.

Pursuant to Title 19 Del.C. §2322F(a), "charges for medical evaluation, treatment and therapy, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice for such charges, accompanied by records or notes, concerning the treatment or services submitted for payment, documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy, with reference to the health care practice guidelines adopted pursuant to §2322C of this title, or documenting the pre-authorization of such evaluation, treatment or therapy."

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19. What can I do if the payer will not pay me correctly?

A certified health care provider may file a petition to determine additional compensation due (DACD) with the Industrial Accident Board if they do not receive correct payment. Except for sole proprietors, providers will need to file their petition through an attorney. Sole proprietors may file a petition with or without an attorney.

The Delaware Code and Administrative Regulations that govern this process are listed below.

Title 19 Del. C. §2322F(a) - "(a) Charges for medical evaluation, treatment and therapy, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice for such charges, accompanied by records or notes, concerning the treatment or services submitted for payment, documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy, with reference to the health care practice guidelines adopted pursuant to §2322C of this title, or documenting the preauthorization of such evaluation, treatment or therapy. The initial copy of the supporting notes or records shall be produced without separate or additional charge to the employer, insurance carrier or employee."

Administrative Regulations for the Introduction & Fee Schedule Guidelines:

"4.15.9 An employer or insurance carrier shall be required to pay a health care invoice within thirty (30) days of receipt of the invoice as long as the claim contains substantially all the required data elements necessary to adjudicate the invoice, unless the invoice is contested in good faith. If the contested invoice pertains to an acknowledged compensable claim and the denial is based upon compliance with the health care payment system and/or health care practice guidelines, it shall be referred to utilization review. Unpaid invoices shall incur interest at a rate of one percent (1%) per month payable to the provider. A provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

4.15.10 If, following a hearing, the Industrial Accident Board determines that an employer, an insurance carrier, or a health care provider failed in its responsibilities under 19 Del.C. §2322B, §2322C, §2322D, §2322E or §2322F, it shall assess a fine of not less than $1,000.00 nor more than $5,000.00 for violations of said sections, such fines shall be payable to the Workers' Compensation Fund."

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20. Is the interest on medical bills owed if the claim is disputed for valid reasons but later determined to be compensable?

Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:

4.15.8 In the event that a portion of a health care invoice is contested, the uncontested portion shall be paid without prejudice with the right to contest the remainder. The time limits set forth above and in §2322F shall apply to payment of all uncontested portions of health care payments.

4.15.9 An employer or insurance carrier shall be required to pay a health care invoice within thirty (30) days of receipt of the invoice as long as the claim contains substantially all the required data elements necessary to adjudicate the invoice, unless the invoice is contested in good faith. If the contested invoice pertains to an acknowledged compensable claim and the denial is based upon compliance with the health care payment system and/or health care practice guidelines, it shall be referred to utilization review. Unpaid invoices shall incur interest at a rate of one percent (1%) per month payable to the provider. A provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

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21. Must bills be submitted on certain forms?

The fee schedule guidelines (for instance 19 DE Admin. Code 1341, Sections 4.18.1 and 4.22.2) require payers to use the latest CMS-1500 and UB-04 forms.

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22. Can you tell me if I am calculating a bill correctly?

No. We can provide general answers, as listed on this web page, but we do not have the resources to address individual calculations.

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23. How should the payer handle a bill with incorrect codes? Can the payer alter the codes on a bill? Does the fee schedule allow for down-coding?

The payer should contact the provider and try to resolve such issues. If the parties cannot resolve the issue a petition may be filed with the state.

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24. When an ambulance travels from one geozip to another, which one should count for billing?

The most common and universally accepted practice is to use the geozip of the place where the patient was picked up.

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25. How do we reimburse assistant surgeons?

Pursuant to the Administrative Regulations for the Introduction and Fee Schedule Guidelines:

"4.21.1.11 Surgical Assistant

4.21.1.11.1 Physician surgical assistant - For the purpose of reimbursement, a physician who assists at surgery is reimbursed as a surgical assistant. Assistant surgeons should use modifier 80 and are allowed twenty percent (20%) of the maximum reimbursement allowance (MRA) for the procedure(s).

4.21.1.11.2 Registered Nurse Surgical Assistant or Physician Assistant

  • A physician assistant (PA), or registered nurses (NP) who have completed an approved first assistant training course, may be allowed a fee when assisting a surgeon in the operating room (O.R.).
  • The maximum reimbursement allowance for the physician assistant or the registered nurse first assistant (RNFA) is twenty percent (20%) of the surgeon's fee for the procedure(s) performed.
  • Under no circumstances will a fee be allowed for an assistant surgeon and a physician assistant or RNFA at the same surgical encounter.
  • Registered nurses on staff in the O.R. of a hospital, clinic, or outpatient surgery center do not qualify for reimbursement as an RNFA."

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26. How do we handle bilateral/multiple procedures?

The Administrative Regulations for the Introduction and Fee Schedule guidelines contain explanations for over 30 different modifiers, including the modifiers for bilateral and multiple procedures. Only those pertinent to this question are pasted below.

Pursuant to the Administrative Regulations for the Introduction and Fee Schedule Guidelines:

4.18.3.9 Modifiers

Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code. If more than one modifier is needed, place modifier 99 after the procedure code to indicate that two or more modifiers will follow. Some modifier descriptions in this fee schedule have been changed from the CPT language.

50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five-digit code.

51 Multiple Procedures: When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes or modifier 51 exempt codes (See CPT Appendix D.)"

Additionally, the Administrative Regulations for the Introduction and Fee schedule guidelines quoted below give billing instructions:

  • 4.23 Multiple Procedures
    • 4.23.1 Multiple Procedure Reimbursement Rules
      • Multiple procedures performed during the same operative session at the same operative site are reimbursed as follows:
        • One hundred percent (100%) of the allowable fee for the primary procedure
        • One hundred percent (100%) of the allowable fee for the second and subsequent procedures
    • 4.23.2 Bilateral Procedure Reimbursement Rule
      • Physicians and staff are sometimes confused by the definition of bilateral. Bilateral procedures are identical procedures (i.e., use the same CPT code) performed on the same anatomic site but on opposite sides of the body.
    • 4.23.3 Multiple Procedure Billing Rules
      • The primary procedure, which is defined as the procedure with the highest RVU, must be billed with the applicable CPT code.
      • The second or lesser or additional procedure(s) may be billed by adding modifier 51 to the codes unless the procedure(s) is exempt from modifier 51 or qualifies as an addon code.

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27. How should providers bill for exposure surgeons as indicated in 7.6 DE Admin Code 1342 of the low back practice guidelines?

In procedures where a surgeon provides exposure and another surgeon performs the primary surgical procedure, each surgeon may bill the CPT code or codes representing their respective part of the operation. Thus, co-surgery rules do not apply. For example, retroperitoneal exposure may be billed as CPT 49010 exploration of the retroperitoneum of the lumbar spine, or CPT 32100 major thoracotomy for the thoracic spine.


REFERENCES:
Title 19 Del C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 5.0
Utilization Review


28. How would a utilization review (UR) provider become eligible to perform utilization review for the Delaware Workers' Compensation Health Care Payment System?

The Department of Labor issues a Request for Proposals (RFP) every 2 years and goes through the State of Delaware contracting process to award contracts to those URAC accredited organizations who will perform utilization review (UR) for the Workers' Compensation Health Care Payment System (HCPS). Interested parties may send an e-mail to hcpaymentquestions@state.de.us if they would like to receive notice during the next contracting cycle. In the e-mail, explain that you would like to go on the mailing list to receive future RFP notices and include complete contact information (name, mailing address, e-mail address and phone number).

The OWC does not administer or govern an organization's internal policies or procedures regarding utilization review. However, Insurance Carriers and self-insured payers may only use a Utilization Review determination processed through the Office of Workers' Compensation to deny a certified health care provider's payment for treatment that applies to one of the practice guidelines in the Delaware Workers' Compensation Health Care Payment System.

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29. How does the law on utilization review affect the process at the OWC?

The OWC issues two year contracts to utilization review (UR) organizations, per State of Delaware procurement requirements. These organizations provide UR for applicable State of Delaware workers' compensation cases. The process Carriers or self-insured employers must use to request a utilization review through the Delaware Office of Workers' Compensation is available by selecting "Utilization Review" from the menu located on the left side of this screen.

We also encourage payers to contact the OWC's Medical Component at 302-761-8200 or hcpaymentquestions@state.de.us, if they need any extra guidance in preparing a Utilization Review Request.

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30. What date should be used to begin counting the number of occurrences when determining a Utilization Review (UR)?

The Delaware Workers' Compensation Health Care Payment System (HCPS) became effective on 05-23-08.The Health Care Advisory Panel clarified that they expect Utilization Reviews under the HCPS to consider treatment, visits, etcetera that occurred on or after 05-23-08 for the 5 initial practice guidelines (carpal tunnel, chronic pain, cumulative trauma, low back, and shoulder). Occurrences involving cervical treatment would count after the 6/1/09 effective date of the cervical practice guidelines. Occurrences involving lower extremities treatment would count after the 6/13/11 effective date of the lower extremities practice guidelines.

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31. What is the deadline for processing a Utilization Review (UR) request?

The Office of Workers' Compensation must receive (clocked-in) a UR request within 15 calendar days from the date of denial. Carriers and employers have 30 days to deny or pay a bill, and then 15 days from the date of that denial to request a UR. The total time required depends on the date the carrier or employer sent the denial; however, the total time may not exceed 45 days (30 days to pay or deny + 15 days to process UR = 45 total days). If the payer denies the bill prior to the 30 days specified in Title 19 Del. C. §2322F(h), then the payer still only has 15 days (clocked in at OWC) from that date to process the UR request.

The issue of compensability is separate from determining whether or not treatment is reasonable or necessary. If the carrier or self-insured employer challenges the compensability (e.g. not casually related to a work accident) of an injury, the injured worker must file a petition to determine compensation due (DCD). If the injury is deemed compensable, the hearing will also determine whether or not the treatment is reasonable and necessary.

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32. Why is it important to specify each treatment modality(s) for review on the "Request for Utilization Review" form (item 8 on the form) versus using the blanket statement "any and all treatment?"

  • The requester may not get a determination on the treatment they really wanted reviewed. This statement leaves the items reviewed up to the interpretation of the UR company. The Department of Labor (DOL) requires our UR contractors to follow URAC standards. As long as they adhere to URAC standards, the UR company's interpretations of what to review are valid when the requester specifies "any and all treatment."
  • The requester may get more determinations than they needed or wanted if the treatment is not identified. In addition, the requester may pay more when the UR company performs utilization review on more than one modality. Each treatment modality may be considered a separate utilization review. As long as the UR company adheres to URAC standards, they may determine what requires a separate utilization review when the requester does not list specific treatment modalities.
  • The insurance carrier or self-insured employer must include "proof of denial" when they send a UR request to the DOL. Those denials usually list the specific treatment modalities. The "proof of denial" notice can give requesters a good starting point when determining what treatment modalities belong in item 8 on the "Request for Utilization Review" form. Keep in mind however, that item 8 must contain a description of the treatment modality and not just CPT/HCPCS codes.
  • Insurance carriers or self-insured employers may also request a utilization review for proposed treatment, which is treatment the provider recommends. The health care provider may recommend treatment in the office notes or may ask for pre-authorization in a separate request to the carrier/self-insured employer, pursuant to subsection 5.4.4, 19 DE Admin Code 1341.

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33. How much does a Utilization Review (UR) cost?

NOTE: UR fees last increased on August 1, 2010

Some UR requests involve more than one utilization review, depending on what is written in item "8" of the "Request for Utilization Review" form. At the request of the Health Care Advisory Panel (HCAP), the Department of Labor requires our UR companies to perform a "like specialist" (level 3) review for any non-certified determinations. UR companies select "like specialists" per URAC standards. The fees for each utilization review performed are below. One UR request and subsequent bill may encompass one or all three levels of review, as well as the multiple utilization reviews that may stem from multiple treatment modalities based on item "8" of the "Request for Utilization Review" form.

LEVEL 1 REVIEW
(Nurse)
$125.00
LEVEL 2 REVIEW
(Medical Director)
$205.00
LEVEL 3 REVIEW
(Specialist)
$305.00
LARGE FILE (>200 pages)
(Supplemental Fee)
$0.72 per page
URGENT OR RUSH
(48 hour response)
Additional $50.00

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34. I have been treating a patient for ongoing pain after a work injury. The case is well over 6 months old, so care falls under the chronic guideline. My treatment has been helping the patient continue to work, however, further care is being denied as "the number of treatments provided" exceeds the guidelines. The documentation shows my care is helping the patient, and is keeping them working. If I don't provide the care, the patient will get worse. What are my options?

Pursuant to 19 Del.C. §2322C(g),

"Services rendered by any health care provider certified to provide treatment services for employees shall be presumed, in the absence of contrary evidence, to be reasonable and necessary if such services conform to the most current version of the Delaware health care practice guidelines..."

and pursuant to 19 Del.C. &sect2322F(j),

"... An employer or insurance carrier may engage in utilization review to evaluate the quality, reasonableness and/or necessity of proposed or provided health care services for acknowledged compensable claims..."

Your best course of action in the case of treatment that relies on something more ambiguous than counting the number of visits is to include clear notes that specify the practice guidelines used, specify how the treatment helps the patient continue to work, and specify how the treatment complies (i.e. what are the functional gains) with the practice guidelines.

In Addition, 19 DE Admin. Code 1342 (the "regulations"), Section 1.0 in the Part B Chronic Pain Treatment Guidelines says:

"...Services rendered outside the Guidelines and/or variation in treatment recommendations from the Guidelines may represent acceptable medical care, be considered reasonable and necessary treatment and, therefore, determined to be compensable, absent evidence to the contrary, and may be payable in accordance with the Fee Schedule and Statute, accordingly...."

That citation in the chronic pain treatment guidelines does not take away the employers' or insurance carriers' ("payers") right to engage in utilization review as specified in 19 Del.C. §2322F(j) and does not guarantee the UR process will certify the provider's treatment. The UR reviewer's sole purpose is to determine whether or not treatment adheres to the health care practice guidelines (PGs) within the Delaware Workers' Compensation Health Care Payment System and is based on the medical documentation available to them at the time of the review. In order to seek payment for treatment that is non-certified through the UR process, a party must appeal the determination, pursuant to 19 DE Admin. Code 1341 (the "regulations"), Section 5.5, which says:

  • 5.5 If a party disagrees with the findings following utilization review, a petition may be filed with the Industrial Accident Board for de novo review. The decision of the utilization review company shall be forwarded by the Department of Labor, by Certified Mail, Return Receipt Requested, to the claimant, the claimant's attorney of record, the health care provider in question, and the employer or its insurance carrier.

In addition, 19 Del. C. §2361(c) gives the following 45 day deadline to appeal the UR determination,

  • (c) Notwithstanding the above, and in furtherance of and accordance with the provisions of § 2322F(j) of this title regarding utilization review, any utilization review decision issued pursuant to applicable rules and regulations promulgated pursuant to § 2322F(j) of this title shall be final and conclusive as to any interested party unless within 45 days from the date of receipt of the utilization review decision any interested party files a petition with the Industrial Accident Board for de novo review.

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35. What are the injured workers' options if a carrier will not pre-authorize a health care service and/or treatment (e.g. surgery), and the certified health care provider will not perform the treatment and/or health care service without a preauthorization?

Prior to 6/13/11, the utilization review program did not require carriers or self-insured employers to respond to a preauthorization request, although they could. Effective 6/13/11, the following regulations were added to 19 DE Admin. Code 1341, Section 5.4, regarding utilization review:

5.4.3 In the instance of a compensable claim where the treatment is outside the applicable Practice Guideline for which the health care provider requests pre-authorization but the employer/carrier advises that it does not pre-authorize treatment, such response should be interpreted as tantamount to a denial of such treatment so that the claimant may file a Petition with the IAB to determine whether the treatment is compensable.

5.4.4 In the instance of a compensable claim in which open surgery is recommended by the health care provider and stated by him/her to be within the applicable Practice Guideline, the following procedure shall be followed to facilitate resolution of payment for such treatment: The operating surgeon must specify the particular surgery to be performed and must certify in writing that: (a) the surgery is causally related to the work accident, and (b) the surgery is within the Practice Guideline, with specific reference to the Practice Guideline provision relied upon.

5.4.4.1 The information set forth above must be set forth by the operating surgeon in a separate written report, not through a copy of office notes and/or records. The employer/carrier must within 30 days from receipt of the above either accept/pre-authorize or deny such treatment. If the treatment is denied as non-compliant with the Practice Guidelines, it must be referred to Utilization Review within 15 days of date of denial in accordance with §2322F(h)(j). If the treatment is denied as not causally related to the compensable work accident, the claimant may file a Petition with the Industrial Accident Board to determine whether the treatment is compensable. If the employer/carrier neither accepts/pre-authorizes nor denies the treatment within the 30-day period referenced above, then the treatment will be deemed compensable if performed.

Keep in mind, utilization review does not pertain to causal relationship issues. If the carrier or self-insured employer disputes whether or not an injury receiving treatment was causally related to a work accident, the injured worker (or his/her attorney) may file a petition to determine compensation due with the OWC in order to establish the claim.

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36. What is the "peer-to-peer conversation" as part of the utilization review process?

In response to requests from certified health care providers, the Delaware Department of Labor, Office of Workers' Compensation added a "peer-to-peer conversation to the utilization review (UR) process. Effective August, 2010, the like-specialist reviewer must make two attempts to reach the provider(s) under review prior to issuing a non-certification determination. This extra step allows provider(s) under review an opportunity to clarify which section(s) of the Delaware workers' compensation health care practice guidelines the provider(s) used to treat the injured worker. If the reviewer cannot reach the health care provider(s) after two attempts during normal 8-5 business hours, then the non-certification determination stands. Once the reviewer issues a UR determination, a party's only recourse is to appeal it by filing a de novo petition with the Industrial Accident Board, pursuant to 19 Del.C. §2322F(j)

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REFERENCES:
Title 19 Del. C. §2322D
Certification of Health Care Providers.

19 DE Admin. Code 1341 - Section 3.0
Health Care Provider Certification


37. Who has to become certified to treat injured workers?

All providers who bill must be certified. The two modifications/exceptions are as follows:

Hospital Modification: Providers treating an injured worker during his/her period of inpatient or outpatient hospitalization. In that circumstance, only physicians, chiropractors and physical therapists in the hospital setting need to be individually certified. All other personnel employed by a hospital providing treatment to an injured worker during his/her period of inpatient or out patient hospitalization are certified as a group by an authorized person/agent of the hospital.

Emergency Room Exception: Pursuant to Title 19 Del.C. §2322B(8)(b), "Health care provider services provided in an emergency department of a hospital, or any other facility subject to the Federal Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd, and any emergency medical services provided in a prehospital setting by ambulance attendants and/or paramedics, shall be exempt from the health care payment system and shall not be subject to the requirements that a health care provider be certified pursuant to §2322D of this title, requirements for preauthorization of services, or the health care practice guidelines adopted pursuant to §2322C of this title.

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38. Does the DOL issue certification numbers to certified health care providers?

No. All users may find the entire certified provider list on the Health Care Payment System (HCPS) web page, so the DOL decided not to issue certification numbers. As of 6/1/09, this information was removed from the Physicians Report of Workers' Compensation Injury ("Physician's Form").

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REFERENCES:
Title 19 Del. C. §2322E
Development of consistent forms for Health Care Providers.

19 DE Admin. Code 1341 - Section 6.0
Forms


39. What CPT code should providers use for the physician's report (provider form) and what is the fee? When should physicians fill out the form?

Use the CPT code 99080 for the physician's report (provider form). The fee for the report is $30. The health care provider most responsible for the injured workers care fills out the physician's form at the first visit and at any subsequent visit where a change occurs in the injured worker's ability to return to work. If the injured worker does not miss time, write "no lost time" on the form at the initial visit. When more than one physician treats an injured worker, only the physician most responsible for the patient's care would fill out the form.

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40. When should I fill out the provider or employer forms?

Provider - For new patients, at the first visit since the new law went into effect on 5/23/08 and any time the health care provider most responsible for the injured workers' care feels a change occurred in the injured workers' ability to return to work, which would include a closing form when the health care provider releases the injured worker from care. For instance, if an injured worker might now qualify for a modified duty, the provider would fill out the form.

Employer - Effective 6/27/13, the employer form provision in 19 Del. C. §2322E(d) changed to the following,

  • (d) Within 14 days of the issuance of an Agreement As To Compensation to an employee for any period of total disability, the employer shall provide to the health care provider/physician most responsible for the treatment of the employee's work-related injury and to the employer's insurance carrier, if applicable, a report of the modified-duty jobs which may be available to the employee. The insurance carrier for an insured employer shall send to such employer the aforementioned report for completion, and shall be independently responsible for providing a completed report of modified-duty jobs to the health care provider--physician. The health care provider portion of the employer's modified duty availability report must be signed and returned by the health care provider within 14 days of the next date of service after receipt of the form from the employer, but not later than 21 days from the health care provider's receipt of such form.

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MISCELLANEOUS


41. How does HIPAA affect workers' compensation?

The U.S. Department of Health and Human Services, Office of Civil Rights (OCR), administers the Health Insurance Portability and Accountability Act (HIPAA). It has issued guidelines that indicate that covered providers may disclose health information to workers' compensation insurers, state administrators, employers, and other entities involved in the workers' compensation system, to the extent disclosure is necessary to comply with, or is required by, state law, or to obtain payment.

The guidelines include a number of frequently asked questions. For more information, please contact the U.S. Department of Health and Human Services

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42. Are any injured workers exempt from coverage under the Delaware Workers' Compensation Act?

Yes. For exemptions please refer to Delaware Code Title 19, Chapter 23, Sections 2307 and 2308.

In addition, seaman, maritime workers, railroad workers and federal employees are covered under federal workers' compensation law. An injured worker covered under federal law would need to contact the appropriate federal office depending on the location of the work accident.

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43. Where can I find a list of the 7/6/09 and 6/27/13 changes to Title 19 Del.C. §2322?

The Governor signed into law Senate Bill No. 38 (145th General Assembly) on 7/6/09 and House Bill No. 175 (147th General Assembly) on 6/27/13. All bills that pass into law are incorporated into the Delaware Code. You may access these bills at the following links:

SB38 (http://legis.delaware.gov/LIS/LIS145.nsf/vwLegislation/SB+38?Opendocument)

HB 175: (http://www.legis.delaware.gov/LIS/LIS147.NSF/vwLegislation/HB+175?Opendocument)

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44. What are the effective dates for each of the Delaware workers' compensation health care practice guidelines?

Users may access the health care practice guidelines on the DOL web page at the link below:

http://dowc.ingenix.com/info.asp?page=pracguid

For treatment that occurred on or after May 23, 2008, 5 practice guidelines went into effect.

  • Part A - Carpal Tunnel Syndrome
  • Part B - Chronic Pain
  • Part C - Cumulative Trauma Disorder
  • Part D - Low Back
  • Part E - Shoulder

For treatment that occurred on or after June 1, 2009, the 6th practice guideline went into effect.

  • Part F - Cervical

For treatment that occured on or after June 13, 2011, the 7th practice guideline went into effect.

  • Part G - Lower Extremities

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