Mass. Gen. Laws ch. 152, sec. 13 — MA Code / Part I / Title XXI / Chapter 152 / Section 13
Rate of payment by insurers; review of clinical health care providers; health care services board
Status: in_force

Section 13. (1) The rate of payment by insurers for health care services adjudged compensable under this chapter shall be established by the executive office of health and human services under chapter 118E or a governmental unit designated by the executive office; provided, however, that a different rate for services may be agreed upon by the insurer, the employer and the health care service provider. Except as provided above, no insurer shall be liable for hospitalization expenses adjudged compensable under this chapter at a rate in excess of the rate set by the said executive office, or for other health services in excess of the rate established for that service by the said executive office, regardless of the setting in which the service is administered; provided, however, that the amount required to be reimbursed by insurers to hospitals for outpatient physical, occupational and speech therapy services only (codes 178010 through 178013, 178050 through 178053, and 178090 through 178093, inclusive) shall be the higher of: (a) the amount required by the said executive office to be reimbursed by insurers to non-hospitals for the above-mentioned outpatient physical, occupational and speech therapy services; and (b) either the amount which can be derived from the ratio of total costs to total charges calculated for the hospital requesting reimbursements, in accordance with methods utilized by the said executive office to determine payment on account factors for hospitals subject to chapter 118E, or ninety-five percent of the rates payable to such hospital for such services on May fifteenth, nineteen hundred and ninety-five, whichever is the lower amount. Requests for reimbursement for health services under this chapter shall be signed by the person performing such service and shall be accompanied by a detailed description of the service rendered as well as the name and licensure number of the person performing such service. All health services provided under this chapter shall be subject to the provisions of section three of chapter one hundred and seventy-five H and 42 CFR 1001.951–1001.953, the so-called ''safe harbor regulations'' as adopted by the federal government on July twenty-ninth, nineteen hundred and ninety-one. No employee shall be liable for health care services adjudged compensable under this chapter. Except with respect to rates to be paid for health care services, as defined in said chapter 118E, which shall be reviewable under said chapter 118E, the commissioner shall by rule establish procedures for determining whether or not the charge for a health service is excessive. In order to accomplish this purpose, the commissioner shall consult with insurers, associations and organizations representing the medical and other providers of treatment services, and other appropriate groups. The charges for such health services shall be reasonable. (2) The department shall review the clinical health care providers who render services to injured employees. This review shall be achieved by establishing a quality control system within the department. The commissioner may hire a medical consultant or consultants, full or part-time, to assist in the administration of this section. Any medical consultant shall be a physician licensed under the laws of the commonwealth. Such medical consultant shall perform all duties assigned by the commissioner relating to the supervision of the total range of care of injured employees and shall also advise the department on matters on which the commissioner requests the consultant's advice. The commissioner shall monitor the medical and surgical treatment provided to injured employees and the services of other health care providers, and shall also monitor hospital utilization as it relates to the treatment of injured employees. The monitoring shall include determinations concerning the appropriateness of the service, whether the treatment is necessary and effective, the proper costs of services, and the quality of treatment. The commissioner with the advice of the health care service board may penalize, disqualify, or suspend a provider from receiving payment for services rendered under this chapter if the commissioner or his designee determines that the provider has violated any part of this chapter or rule adopted under this chapter. The commissioner shall have the sole authority to make determinations under this section; provided, however, that aggrieved parties shall have a right to appeal to the superior court. (3) There is hereby created a health care services board composed of the commissioner or his designee as an ex officio member and chairman, one person representing chiropractors, one person representing dentists, one person representing hospital administrators, one person representing physical therapists, and six physicians representing different health care specialties which the commissioner determines are the most frequently utilized by injured employees. The board shall also have one person representing employees, one person representing employers, and one person representing the public. Members shall be appointed by the commissioner for two-year terms. The health care services board shall receive and investigate complaints from employees, employers and insurers regarding health care providers who provide services under this chapter who are alleged to have engaged in patterns of (i) discrimination against compensation claimants, (ii) overutilization of procedures, (iii) unnecessary surgery or other procedures, or (iv) other inappropriate treatment of compensation recipients. Where such board finds a pattern of abuse, it shall refer its findings to the appropriate board of registration. No member of the health care services board shall be liable for damages resulting from any investigation under this paragraph in any action brought by any party against such board or any individual member thereof, provided that the performance of the duties of such member were undertaken in good faith. The health care services board shall develop itself or the commissioner may contract with one or more organizations with demonstrated expertise in the treatment of work-related injuries and illnesses to develop written guidelines for appropriate and necessary treatment based on diagnosis of injuries and illnesses. Said guidelines shall include appropriate mechanisms for deviation of treatment. The board shall no later than July first, nineteen hundred and ninety-two, distribute said guidelines in draft form for public comment and no later than January first, nineteen hundred and ninety-three, endorse the first version of said guidelines for use by health care providers in the treatment of injuries and illnesses under this chapter. The board shall at least annually review and where appropriate revise said guidelines. The cost of any contract for development, review, revision or dissemination of said guidelines shall be paid out of the Workers' Compensation Special Fund pursuant to section sixty-five. The health care services board shall develop criteria in order to select and maintain a roster of qualified impartial physicians to provide objective medical opinions pursuant to sections eight and eleven A of this chapter. Said criteria shall further be used, when necessary, to remove any impartial physicians from the roster when a medical provider fails to comply with the criteria. Upon the establishment of criteria, the health care services board shall refer said criteria to the senior administrative judge who shall develop a roster of impartial physicians. The commissioner shall have the authority to hire the personnel necessary to carry out the duties of the board pursuant to this section.

Section 13. (1) The rate of payment by insurers for health care services adjudged compensable under this chapter shall be established by the executive office of health and human services under chapter 118E or a governmental unit designated by the executive office; provided, however, that a different rate for services may be agreed upon by the insurer, the employer and the health care service provider.

Except as provided above, no insurer shall be liable for hospitalization expenses adjudged compensable under this chapter at a rate in excess of the rate set by the said executive office, or for other health services in excess of the rate established for that service by the said executive office, regardless of the setting in which the service is administered; provided, however, that the amount required to be reimbursed by insurers to hospitals for outpatient physical, occupational and speech therapy services only (codes 178010 through 178013, 178050 through 178053, and 178090 through 178093, inclusive) shall be the higher of:

(a) the amount required by the said executive office to be reimbursed by insurers to non-hospitals for the above-mentioned outpatient physical, occupational and speech therapy services; and

(b) either the amount which can be derived from the ratio of total costs to total charges calculated for the hospital requesting reimbursements, in accordance with methods utilized by the said executive office to determine payment on account factors for hospitals subject to chapter 118E, or ninety-five percent of the rates payable to such hospital for such services on May fifteenth, nineteen hundred and ninety-five, whichever is the lower amount.

Requests for reimbursement for health services under this chapter shall be signed by the person performing such service and shall be accompanied by a detailed description of the service rendered as well as the name and licensure number of the person performing such service. All health services provided under this chapter shall be subject to the provisions of section three of chapter one hundred and seventy-five H and 42 CFR 1001.951–1001.953, the so-called ''safe harbor regulations'' as adopted by the federal government on July twenty-ninth, nineteen hundred and ninety-one. No employee shall be liable for health care services adjudged compensable under this chapter.

Except with respect to rates to be paid for health care services, as defined in said chapter 118E, which shall be reviewable under said chapter 118E, the commissioner shall by rule establish procedures for determining whether or not the charge for a health service is excessive. In order to accomplish this purpose, the commissioner shall consult with insurers, associations and organizations representing the medical and other providers of treatment services, and other appropriate groups. The charges for such health services shall be reasonable.

(2) The department shall review the clinical health care providers who render services to injured employees. This review shall be achieved by establishing a quality control system within the department. The commissioner may hire a medical consultant or consultants, full or part-time, to assist in the administration of this section. Any medical consultant shall be a physician licensed under the laws of the commonwealth.

Such medical consultant shall perform all duties assigned by the commissioner relating to the supervision of the total range of care of injured employees and shall also advise the department on matters on which the commissioner requests the consultant's advice.

The commissioner shall monitor the medical and surgical treatment provided to injured employees and the services of other health care providers, and shall also monitor hospital utilization as it relates to the treatment of injured employees. The monitoring shall include determinations concerning the appropriateness of the service, whether the treatment is necessary and effective, the proper costs of services, and the quality of treatment. The commissioner with the advice of the health care service board may penalize, disqualify, or suspend a provider from receiving payment for services rendered under this chapter if the commissioner or his designee determines that the provider has violated any part of this chapter or rule adopted under this chapter.

The commissioner shall have the sole authority to make determinations under this section; provided, however, that aggrieved parties shall have a right to appeal to the superior court.

(3) There is hereby created a health care services board composed of the commissioner or his designee as an ex officio member and chairman, one person representing chiropractors, one person representing dentists, one person representing hospital administrators, one person representing physical therapists, and six physicians representing different health care specialties which the commissioner determines are the most frequently utilized by injured employees. The board shall also have one person representing employees, one person representing employers, and one person representing the public. Members shall be appointed by the commissioner for two-year terms. The health care services board shall receive and investigate complaints from employees, employers and insurers regarding health care providers who provide services under this chapter who are alleged to have engaged in patterns of (i) discrimination against compensation claimants, (ii) overutilization of procedures, (iii) unnecessary surgery or other procedures, or (iv) other inappropriate treatment of compensation recipients. Where such board finds a pattern of abuse, it shall refer its findings to the appropriate board of registration. No member of the health care services board shall be liable for damages resulting from any investigation under this paragraph in any action brought by any party against such board or any individual member thereof, provided that the performance of the duties of such member were undertaken in good faith. The health care services board shall develop itself or the commissioner may contract with one or more organizations with demonstrated expertise in the treatment of work-related injuries and illnesses to develop written guidelines for appropriate and necessary treatment based on diagnosis of injuries and illnesses. Said guidelines shall include appropriate mechanisms for deviation of treatment. The board shall no later than July first, nineteen hundred and ninety-two, distribute said guidelines in draft form for public comment and no later than January first, nineteen hundred and ninety-three, endorse the first version of said guidelines for use by health care providers in the treatment of injuries and illnesses under this chapter. The board shall at least annually review and where appropriate revise said guidelines. The cost of any contract for development, review, revision or dissemination of said guidelines shall be paid out of the Workers' Compensation Special Fund pursuant to section sixty-five.

The health care services board shall develop criteria in order to select and maintain a roster of qualified impartial physicians to provide objective medical opinions pursuant to sections eight and eleven A of this chapter. Said criteria shall further be used, when necessary, to remove any impartial physicians from the roster when a medical provider fails to comply with the criteria. Upon the establishment of criteria, the health care services board shall refer said criteria to the senior administrative judge who shall develop a roster of impartial physicians.

The commissioner shall have the authority to hire the personnel necessary to carry out the duties of the board pursuant to this section.