State workers' compensation officials have adopted a new physician fee schedule that raises payments for most services, including evaluation and management, from 125 percent to 140 percent of Medicare rates. Fees for surgical services in hospitals, ambulatory surgical centers, or other facilities will rise from 125 percent to 175 percent of Medicare. The new rates take effect in March.
The new rates adopted by the Texas Department of Insurance Division of Workers' Compensation apply only to services provided on an out-of-network basis. Physicians and commercial health plans negotiate in-network rates. However, TMA physician leaders expect the increased out-of-network rates to pressure the network health plans to improve in-network "market-based" rates as physicians will likely consider out-of-network market rates when they negotiate their contracts.
TMA sought a larger rate increase that would have brought Texas more in line with national averages. TMA proposed 155 percent of Medicare for most medical services and 190 percent for all surgical services, both in facilities and for minor surgeries in physicians' offices.
"The best news for physicians is that along with the fee increases, the workers’ compensation system in Texas no longer has to endure sudden and unexpected shifts in Medicare rates based on political decisions made by Congress and its struggle with the sustainable growth rate," said Michael Reed, MBA, MPA, director of TMA's Managed Care Delivery Systems Department. "The new Texas workers’ compensation rates will be based on conversion factors that will be adjusted annually using the Medicare Economic Index (MEI). The MEI is the weighted average of price changes for goods and services used to deliver physician services."
Mr. Reed said TMA has "consistently asked legislators and regulators to reform the broken workers' compensation system for injured workers and employers," adding that the new rates address some of the association's concerns, and that the new fee schedule is "an important step in the right direction. However we must still work to reduce administrative hassles and burdens that prohibit most physicians from accepting workers’ compensation patients."
The February Texas Medicine will have more on the rate increase, including concerns that the new rates are not high enough to convince physicians who left the system to return.
San Antonio occupational medicine physician Bernard T. Swift Jr., DO, MPH, told Texas Medicine that the rates will "come closer to getting more people interested" in workers' compensation, but he believes TMA's proposed rates would have provided a better chance of increasing access to care.
"I think you would have had a much greater opportunity to sign up primary care physicians, in particular," Dr. Swift said. "We are certainly hopeful that physicians will return to the system based on the new rates, but I think it remains to be seen as to whether that, in fact, will happen."
Other changes adopted with these rules include these:
· Incentive payments to physicians in areas of the state where injured workers are underserved. Physicians in 122 of the state’s 4,254 ZIP Codes will get a 10-percent incentive on top of the fee-schedule amount;
· New fees and modifiers for workers’ compensation specific case-management responsibilities by physicians;
· New reimbursements with modifiers associated with the expanded duties of designated doctors;
· New billing and reimbursement methods for an impairment rating evaluation in circumstances when there is no test to determine an impairment rating for a non-musculoskeletal condition.
Last Published: 1/14/2008
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