Current through Register Vol. 51, No. 3, September 1, 2024
RELATES TO: KRS 342.0011(32), 342.019, 342.020, 342.035
NECESSITY, FUNCTION, AND CONFORMITY: KRS 342.035(1) requires
the commissioner of the Department of Workers' Claims to promulgate
administrative regulations to ensure that all fees, charges, and reimbursements
for medical services under KRS Chapter 342 are limited to charges that are
fair, current, and reasonable for similar treatment of injured persons in the
same community for like services, where treatment is paid for by general health
insurers. KRS 342.035(4) requires the commissioner to promulgate an
administrative regulation establishing the workers' compensation medical fee
schedule for physicians. Pursuant to KRS 342.035 requires a schedule of fees to
be reviewed and updated, if appropriate, every two (2) years on July 1. This
administrative regulation establishes the medical fee schedule for
physicians.
Section 1. Definitions.
(1) "Medical fee schedule" means the 2024
Kentucky Workers' Compensation Schedule of Fees for Physicians.
(2) "Physician" is defined by KRS 342.0011(32).
Section 2.
Services Covered.
(1) The medical fee schedule
shall govern all medical services provided to injured employees by physicians
under KRS Chapter 342.
(2) The
medical fee schedule shall also apply to other health care or medical services
providers to whom a listed CPT, HCPCS, or Transportation code, is applicable
unless:
(a) Another fee schedule of the
Department of Workers' Claims applies;
(b) A lower fee is required by KRS 342.035 or
a managed care plan approved by the commissioner pursuant to 803 KAR 25:110;
or
(c) An insurance carrier,
self-insured group, or self-insured employer has an agreement with a physician,
medical bill vendor, or other medical provider to provide reimbursement of a
medical bill at an amount lower than the medical fee schedule.
Section 3. Fee
Computation.
(1) The appropriate fee for a
procedure or item covered by the medical fee schedule shall be the Maximum
Allowable Reimbursement (MAR) listed in the 2024 Kentucky Workers' Compensation
Schedule of Fees for Physicians for those procedures or items for which a
specific monetary amount is listed.
(2) Procedures Listed Without Specified
Maximum Allowable Reimbursement Monetary Amount. The appropriate fee for a
procedure or item for which no specific monetary amount is not listed shall be
determined and calculated in accordance with numerical paragraph seven (7) of
the General Instructions of the medical fee schedule unless more specific
Ground Rules are applicable to that service or item, in which case the fee
shall be calculated in accordance with the applicable Ground Rules.
(3) The resulting fee shall be the maximum
fee allowed for the service provided.
Section 4.
(1) A physician or healthcare or medical
services provider located outside the boundaries of Kentucky shall be deemed to
have agreed to comply with this administrative regulation if it treats a
patient who is covered under KRS Chapter 342.
(2) Pursuant to KRS 342.035, medical fees due
to an out-of-state physician or healthcare or medical services provider shall
be calculated under the fee schedule in the same manner as for an in-state
physician.
Section 5.
Incorporation by Reference.
(1) "2024 Kentucky
Workers' Compensation Schedule of Fees for Physicians", July 1, 2024 Edition,
is incorporated by reference.
(2)
This material may be inspected, copied, or obtained, subject to applicable
copyright law, at the Department of Workers' Claims, Mayo-Underwood Building
3rd Floor, 500 Mero Street, Frankfort, Kentucky 40601, Monday through Friday, 8
a.m. to 4:30 p.m.
(3) The fee
schedule may be obtained directly from FAIR Health, Inc., at
https://orders.fairhealth.org/. A
link to FAIR Health, Inc., may be found on the Department of Workers' Claims
Web site at
https://elc.ky.gov/Workers-Compensation/Pages/Medical-Services.aspx.
STATUTORY AUTHORITY: KRS 342.020, 342.035(1),
(4)
