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Summary of 2015 Revisions to NC Workers Compensation Medical Fee Schedule

Summary of 2015 Revisions to NC Workers Compensation Medical Fee Schedule


Health Care Law Note
(March 19, 2015)

The N.C. Industrial Commission approved a revised Medical Fee Schedule in February 2015 that will take effect April 1, 2015 for hospitals and ambulatory surgery centers and July 1, 2015 for professional services. The full text of the rule changes can be found on the Industrial Commission's web site or in volume 29:10 of the North Carolina Register (pp. 1192-96).

For professional services (those billed using a CMS Form 1500), the revisions link reimbursement to current and future years' Medicare Part B Fee Schedule for North Carolina, as opposed to the current fee schedule, which generally provides for a fixed reimbursement rate based on the 1995 North Carolina Medicare amounts.  The multipliers applied to the Medicare reimbursement amounts vary by type of service; therefore, the net effect of the revisions will vary among types of professional services and will depend on the changes in the Medicare reimbursement rates since 1995.

The revisions also affect institutional services (those billed via a UB-04/CMS Form 1450), including hospital and ambulatory surgery center services.  Hospital inpatient services were previously reimbursed based on the amount reimbursed per-DRG by the State Health Plan in 2001, subject to maximum and minimum payments based on percentages of the hospital's itemized charges.  In contrast, the revised fee schedule links hospital inpatient services reimbursement to current and future years' Medicare facility-specific rates.  Hospital outpatient reimbursement and ambulatory surgery center reimbursement were previously based on percentages of billed charges.  However, as with inpatient services, the revised fee schedules link hospital outpatient and ambulatory surgery center reimbursement to current and future Medicare facility-specific rates.

Following the April 1, 2015 effective date of the changes to reimbursement for institutional services, the rates will decrease as a percentage of the Medicare rate on January 1st 2016, and again on January 1st, 2017.

Click here to view the table that summarizes the reimbursement changes for each type of service and references the relevant rule sections.

Marc Hewitt is a partner at Smith Moore Leatherwood. He practices from our Raleigh office and can be reached at (919) 755-8776.

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