About Regulation 83 and the No-Fault Fee Schedule
Q: Where can I obtain a copy of the Workers' Compensation Board (WCB) Medical Fee Schedule?
A: Copies of the WCB Medical Fee Schedule can be purchased from INGENIX by calling 1-800-INGENIX (1-800-464-3649).
Where can I obtain a copy of the new Medicaid Fee Schedule?
A: You must contact the Computer Sciences Corporation Technical Support Unit 800 North Pearl Street Albany, NY 12204. There is a $20.00 charge for non-Medicaid providers. (800) 522-5518, or (800) 522-5535.
Q: What is a CPT code?
A: A CPT code is a method used in describing the type of procedure rendered to patients. CPT stands for Current Procedural Terminology. CPT is a registered trademark of the American Medical Association.
What is the correct method of billing for an in-patient hospital stay?
A: The New York State Department of Financial Services has adopted the State of New York Department of Health (DOH), Office of Health Systems Management, DRG system for No-Fault related in-patient hospital billing as required by Regulation No. 83, Section 68.2. Under Section 2807-c of the Public Health law (applicable to No-Fault), reimbursements for inpatient hospital billings are made on an individually calculated case based payment per patient discharge ("DRG"). A DRG rate cannot be accurately calculated before a patients discharge, as one of the variables necessary for the calculation is the discharge diagnosis. Any initial payments made based upon an admission of the patient will be reconciled upon discharge. In addition, a hospital is not prohibited from resubmitting an amended/corrected in-patient hospital bill to an insurer if the incorrect DRG rate was inadvertently calculated. If you have any questions regarding the DRG system, you can contact the State of New York Department of Health or review section 2807-c of the Public Health law.
Q: What is the correct billing procedure to be followed by a licensed massage therapist (LMT) when billing for services rendered to No-Fault patient?
A: The Department of Financial Services has not established a fee schedule applicable to a massage therapist. However, the amount a massage therapist can charge is controlled by Regulation No. 83, Section 68.5 (b), which allows massage therapists to bill at the prevailing rate in the geographical area of the provider. Note that an insurer can review a bill and possibly reduce it if the insurer believes that the bill is not consistent with charges for similar procedures in an established fee schedule adopted by the Superintendent of Insurance. Any reduction by an insurer to the charges billed by a health care provider must be denied and can be resolved through arbitration or litigation.
Q: Can a provider bill 150% of the documented cost (invoice) for medical supplies and Durable Medical Equipment (DME) provided to a No-Fault patient?
A: For DMEs supplied to a No-Fault patient prior to October 6, 2004 (the promulgation of the 28th Amendment to Regulation 83), reimbursement was governed by Regulation 83, Part E: Drugs, Medical Equipment and Supplies, which stated that for medical equipment and supplies (e.g. TENS units, soft cervical collars) provided by a physician or medical equipment supplier, the maximum permissible charge is 150% of the documented cost of the equipment to the provider. The documented cost of DME is limited to costs incurred by a provider in a bona fide arms length transaction.
Effective October 6, 2004, the maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, orthopedic footwear and orthotic and prosthetic appliances is the fee payable for such equipment and supplies under the New York State Medicaid program at the time such equipment and supplies are provided. If the New York State Medicaid program has not established a fee payable for the specific item, then the fee payable, in accordance with Medicaid rules, shall be the lesser of:
the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; or
- the usual and customary price charged to the general public.
If a dispute arose as to whether a provider's documented wholesale cost was unreasonable or excessive in a competitive marketplace, this would constitute a question of fact, which should be submitted to No-Fault arbitration or a court of competent jurisdiction for resolution.
Q: Is there any restriction on any health care provider from prescribing drugs to No-Fault patients under Regulation No. 83?
A: There is no rule restricting a health care provider from prescribing drugs to No-Fault patients unless the health care provider's license prohibits it.
What is the fee schedule for an licensed Acupuncturist?
A: Currently there is no specific fee schedule applicable to a licensed acupuncturist, however there is a fee schedule for physicians and chiropractors in the workers compensation fee schedule who perform acupuncture. However, Regulation 83, Section 68.5(b) [11NYCRR68.5(b)] provides that if the superintendent has not adopted or established a fee schedule applicable to a particular provider, then the permissible charge for such service shall be the prevailing fee in the geographic location of the provider subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent.
For example, the insurer could dispute the fees charged by a licensed acupuncturist based on those established within existing fee schedules for similar procedures rendered by a chiropractor or physician who are licensed or certified in acupuncture.
If the licensed acupuncturist and the No-Fault insurer cannot agree on the correct level of reimbursement for services rendered, that would constitute a question of fact which should be submitted to No-Fault arbitration or a court of competent jurisdiction for resolution.
Q: Can a certified social worker bill for psychotherapy services under No-Fault?
A: Yes. The fees are governed under 11NYCRR 68.5(b).
Q: A chiropractor submits a narrative report with the first office visit. Is he entitled to be reimbursed for this report in addition to the office visit?
A: No, a narrative report is required by the fee schedule.
Q: What is the correct fee schedule amount to be charged for ambulance transportation under the New York State No-Fault fee schedule?
A: Regulation No. 83, Part G contains the No-Fault fee schedule for ambulance transportation. Pursuant to this schedule, the maximum permissible charge for ambulance service is the local prevailing charge for such service in the geographic area where rendered.
Q: When a patient is covered by New York State No-Fault and is treated outside of the State of New York, how is this billed?
A: The health provider may bill at the prevailing fee for the geographic location of the health provider.
Q: What are the fee schedule requirements for reimbursement of biofeedback services?
A: The fee schedule requirements for reimbursement of biofeedback are contained within Rule 1 of the Workers' Compensation Board Medical Fee Schedule, and the fee schedule requirements for biofeedback rendered as a psychological treatment are contained within Rule 1 of the Psychology Fee Schedule (note that WCB pre-authorization requirements are not applicable to No-Fault). These ground rules would control, and biofeedback would be reimbursable only if it is performed by either a licensed physician or a psychologist.
Q: Would a medical PC be eligible for reimbursement for biofeedback services rendered by a technician, working under direct and personal supervision of a Board certified internist, both of whom possess a training certificate in biofeedback?
A: No. Only those services actually performed by the licensed professional (i.e.: an internist) which are within the lawful scope of the licensee's practice are eligible for reimbursement by No-Fault. If the licensee through professional education and training were qualified to perform biofeedback, then the licensee (or their PC) would be eligible for reimbursement for biofeedback. Although it is permissible for a technician certified in biofeedback to work under the direct and personal supervision of a Board Certified internist who is also certified in biofeedback, inasmuch as the technician is not professionally licensed the services performed by the technician are not eligible for reimbursement under No-Fault.
Q: What is the correct fee schedule amount to be charged for a medical service or procedure that does not have a specific unit value listed in the Workers' Compensation Board Medical Fee Schedule?
A: Although most medical services and procedures are included within the Workers' Compensation Board Medical Fee Schedule, certain services are relatively unique in nature and do not have a specific unit value indicated within the fee schedule. These procedures are referred to as BR, or 'by report' items. Fees for such services must be justified by the submission of a written report. The provider shall establish a unit value consistent in relativity with other unit values shown in the fee schedule.
If the health provider and the No-Fault insurer cannot agree on the correct level of reimbursement for services rendered, that would constitute a question of fact which should be submitted to No-Fault arbitration or a court of competent jurisdiction for resolution.
Q: My doctor accepted a No-Fault assignment and rendered treatment. My insurer recently issued a denial of claim based on the results of an insurer medical examination. Can the doctor bill me directly?
A: No. By accepting an assignment, the health care provider (assignee) entered into a contract with the injured party (assignor). If the insurer denied payment for medical services rendered based on the results of an insurer medical examination (IME), the assignee must pursue a remedy in court or arbitration. A health care provider who accepted an assignment of benefits from a No-Fault patient cannot bill the patient directly if the submitted claim was denied based on an insurer medical examination.
However, an assignment may be revoked by an assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions of conduct of the assignor.
Q: What happens if my claim is denied?
If the claim is denied the assignee may file a consumer complaint with this Department by including a copy of the assignment of benefits form. Additionally, the assignee may proceed with no fault arbitration. The instructions for filing no fault arbitration are included on the back of the No Fault Denial of Claim Form (NF-10).
Q: The insurance company reduced the amount of a medical bill to the Workers' Compensation fee schedule charges. Am I responsible to pay my doctor the difference between "fee schedule" and the amount he/she previously billed?
A: No. A health care provider is required by Section 5108 of the Insurance Law to bill in accordance with the No-Fault fee schedules. A provider can not balance bill a patient for fees in excess of those contained in the fee schedule.
Q: A health provider continuously submits bills that are not at Workers' Compensation fee schedule charges. Payment is issued by the insurer for the correct fee schedule amount and excess charges are denied. Although the health provider has not disputed any prior fee schedule reductions, the provider continues to bill in excess of the fee schedule. What can an insurer do to correct this provider's behavior?
A: If a health care provider has established a pattern of billing more than what is allowable by the No-Fault fee schedules in violation of the requirements of Section 5108 of the Insurance Law, insurers should report such overcharging to the Department as required by Section 68.8 of Regulation 83. The Department of Financial Services will report to the appropriate authorities those health care providers who continue to bill in excess of the fee schedule.
Q: If the insurer denies payment for continued health care based on a question of medical necessity and the patient decides to file for arbitration, is the health provider required to continue to bill in accordance with the No-Fault fee schedule?
A: Yes, the provider must continue to bill at No-Fault fee schedule rates in this instance. If continued treatment is denied based upon the results of an insurer medical examination or a peer review, this constitutes a question of medical fact which must be resolved through No-Fault arbitration or a court of competent jurisdiction.
Q: What is the effective date of the 28th Amendment to Regulation 83, and does it affect existing claims or only new claims?
A: October 6, 2004. The changes effected by the 28th Amendment to Regulation 83 would be applicable to claims with a dates of service occurring on or after October 6, 2004. If a claim contains dates of service which are both prior to and after October 6, 2004, the portion of the claim incurred prior to that date would not be subject to the 28th Amendment to Regulation 83.
How can I confirm if a health provider is licensed in New York?
A: You may contact the New York State Education Department (NYSED), Office of Professions, to inquire whether a provider is licensed. You can also go to the NYSED website at http://usny.nysed.gov/professionals/ for online license verification.
The 29th Amendment to Regulation 83
What was the purpose of the 29th Amendment to Regulation 83?
A: The changes implemented by the 29th Amendment to Regulation 83 were required in order to update the mailing address (of the NYS Department of Health and the NYS Department of Education) to be used by insurers when reporting any pattern of overcharging, excessive treatment or other improper actions committed by physicians or physician's assistants, hospitals, or other health providers.
HEALTH PROVIDER FAQs
When using the Workers' Compensation Board (WCB) Medical Fee Schedule to bill, are health providers bound by the preauthorization requirements contained in the fee schedule?
A: No. Regulation No. 83, Section 68.1(b)(1) states that the general instructions and ground rules in the WCB Medical Fee Schedule applies to No-Fault claims, however those ground rules which refer to workers' compensation claim forms, pre-authorization approval and dispute resolution guidelines do not apply to No-Fault.
I accepted a No-Fault assignment from a patient and rendered treatment. When I submitted the bill to the No-Fault insurer, they issued a denial of claim based on the results of an insurer medical examination (IME). Can I pursue the patient directly for payment of this bill?
A: No. A physician who has accepted a No-Fault assignment of benefits from a No-Fault patient may not pursue the patient directly for payment if the No-Fault carrier denies payment for services based upon a determination that the services were not medically necessary. Such action by the provider would not be permitted under the No-Fault assignment of benefits language contained in claim forms required by N.Y. Comp. Codes R. & Regs. tit. 11, 65-3.11(b)(ii) & (iv) (2002) (Regulation 68-C).
The No-Fault assignment is considered a legal contract, wherein the health provider assignee assumes all of the legal rights and privileges of the injured party assignor. The assignee cannot arbitrarily disregard the provisions of a previously accepted No-Fault assignment. Inasmuch as a No-Fault assignment of benefits has been accepted and the No-Fault insurer denied continued treatments as not necessary or related to an automobile accident, the health provider is legally bound to resolve this question of fact through No-Fault arbitration or through a court of competent jurisdiction if they are in disagreement with the insurers denial of claim. A failure to exercise these remedies constitutes an acceptance of the insurers determination that health services rendered were not necessary, and under the terms of the assignment the health provider may not bill the patient for services rendered.
If a hospital submits a bill to No-Fault for amount less than the maximum permissible DRG rate, would the No-Fault insurer base it's claim payment on the amount billed by the hospital or the actual DRG rate?
A: As required by Article 28 of the Public Health Law, The New York State Department of Financial Services has adopted the State of New York Department of Health, Office of Health Systems Management, Diagnostic Related Group (DRG) system for No-Fault related in-patient hospital billing through Regulation No. 83, Section 68.2. Article 28, Section 2807 of the Public Health Law states:
“(b-1) (i) For patients discharged on and after January first, nineteen hundred ninety-seven and prior to January first, two thousand and on and after January first, two thousand, payments to general hospitals for reimbursement of inpatient hospital services provided to patients eligible for payments pursuant to the workers' compensation law, the volunteer firefighters' benefit law, the volunteer ambulance workers' benefit law, and the comprehensive motor vehicle insurance reparations act shall be at the rates of payment determined pursuant to this section for state governmental agencies, excluding adjustments pursuant to subdivision fourteen-f of this section."
Based on the foregoing, all charges for hospital inpatient services must be billed and reimbursed in accordance with the DRG rates established by the New York State Health Department. If the hospital billed at a rate less than the maximum permissible DRG rate, the No-Fault insurer must still base it's claim payment on the actual DRG rate.