Source: https://vacode.org/65.2-605/
Timestamp: 2020-06-01 12:41:28
Document Index: 648713864

Matched Legal Cases: ['§ 65', '§ 65', '§ 65', '§ 32', '§ 54', '§ 65', '§ 2', '§ 2', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65']

Liability of employer for medical services ordered by Commission; fee schedules for medical services; malpractice; assistants-at-surgery; coding (§ 65.2-605)—Virginia Decoded - Virginia Decoded
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§ 65.2-605 Liability of employer for medical services ordered . . .
§ 65.2-605
Liability of employer for medical services ordered by Commission; fee schedules for medical services; malpractice; assistants-at-surgery; coding
A. As used in this section, unless the context requires a different meaning:”Burn center” means a treatment facility designated as a burn center pursuant to the verification program jointly administered by the American Burn Association and the American College of Surgeons and verified by the Commonwealth.”Categories of providers of fee scheduled medical services” means:
7. Purveyors of miscellaneous items and any other providers not described in subdivisions 1 through 6, as established by the Commission in regulations adopted pursuant to subsection C.”Codes” means, as applicable, CPT codes, HCPCS codes, or DRG classifications.”"CPT codes” means the medical and surgical identifying codes using the Physicians’ Current Procedural Terminology published by the American Medical Association.”Diagnosis related group” or “DRG” means the system of classifying in-patient hospital stays adopted for use with the Inpatient Prospective Payment System.”Fee scheduled medical service” means a medical service exclusive of a medical service provided in the treatment of a traumatic injury or serious burn.”Health Care Common Procedure Coding System codes” or “HCPCS codes” means the medical coding system used to report hospital outpatient and certain physician services as published by the National Uniform Billing Committee, including Temporary National Code (Non-Medicare) S0000-S-9999.”Level I or Level II trauma center” means a hospital in the Commonwealth designated by the Board of Health as a Level I trauma center or a Level II trauma center pursuant to the Statewide Emergency Medical Services Plan developed in accordance with § 32.1-111.3.”Medical community” means one of the following six regions of the Commonwealth:
6. Far Southwest region, consisting of the area for which three-digit ZIP code prefixes 242, 243, and 246 have been assigned by the U.S. Postal Service.”Medical service” means any medical, surgical, or hospital service required to be provided to an injured person pursuant to this title.”Miscellaneous items” means medical services provided under this title that are not included within subdivisions 1 through 6 of the definition of categories of providers of fee scheduled medical services. “Miscellaneous items” does not include (i) pharmaceuticals that are dispensed by providers, other than hospitals or Type One teaching hospitals as part of inpatient or outpatient medical services, or dispensed as part of fee scheduled medical services at an ambulatory surgical center or (ii) durable medical equipment dispensed at retail.”Physician” means a person licensed to practice medicine or osteopathy in the Commonwealth pursuant to Chapter 29 (§ 54.1-2900 et seq.) of Title 54.1.”Provider” means a person licensed by the Commonwealth to provide a medical service to a claimant under this title.”Reimbursement objective” means the average of all reimbursements and other amounts paid to providers in the same category of providers of fee scheduled medical services in the same medical community for providing a fee scheduled medical service to a claimant under this title during the most recent period preceding the transition date for which statistically reliable data is available as determined by the Commission.”Serious burn” means a burn for which admission or transfer to a burn center is medically necessary.”Transition date” means the date the regulations of the Commission adopting initial Virginia fee schedules for medical services pursuant to subsection C become effective.”Traumatic injury” means an injury for which admission or transfer to a Level I or Level II trauma center is medically necessary and that is assigned a DRG number of 003, 004, 011, 012, 013, 025 through 029, 082, 085, 453, 454, 455, 459, 460, 463, 464, 465, 474, 475, 483, 500, 507, 510, 515, 516, 570, 856, 857, 862, 901, 904, 907, 908, 955 through 959, 963, 998, or 999. Claimants who die in an emergency room of trauma or burn before admission shall be deemed to be claimants who incurred a traumatic injury.”Type One teaching hospital” means a hospital that was a state-owned teaching hospital on January 1, 1996.”Virginia fee schedule” means a schedule of maximum fees for fee scheduled medical services for the medical community where the fee scheduled medical service is provided, as initially adopted by the Commission pursuant to subsection C and as adjusted as provided in subsection D.
b. In the absence of a contract described in subdivision 3 a, an amount equal to 80 percent of the provider’s charge for the service based on the provider’s charge master or schedule of fees; however, if the compensability under this title of a claim for traumatic injury or serious burn is contested and after a hearing on the claim on its merits or after abandonment of a defense by the employer or insurance carrier, benefits for medical services are awarded and inure to the benefit of a third-party insurance carrier or health care provider and the Commission awards to the claimant’s attorney a fee pursuant to subsection B of § 65.2-714, then the pecuniary liability of the employer for the service provided shall be limited to 100 percent of the provider’s charge for the service based on the provider’s charge master or schedule of fees.
1. The Commission’s regulations that establish the initial Virginia fee schedules shall be effective on January 1, 2018.
4. In establishing the initial Virginia fee schedules for fee scheduled medical services, the Commission shall establish the maximum fee for each fee scheduled medical service at a level that approximates the reimbursement objective for each category of providers of fee scheduled medical services among the medical communities. The Commission shall retain a firm with nationwide experience and actuarial expertise in the development of workers’ compensation fee schedules to assist the Commission in establishing the initial Virginia fee schedules. The Commission shall consult with the regulatory advisory panel established pursuant to subdivision F 2 prior to retaining such firm. Such firm shall be retained to assist the Commission in developing the Virginia fee schedules by recommending a methodology that will provide, at reasonable cost to the Commission, statistically valid estimates of the reimbursement objective for fee scheduled medical services within the medical communities, based on available data or, if the necessary data is not available, by recommending the optimal methodology for obtaining the necessary data. The Commission shall consult with the regulatory advisory panel prior to adopting any such methodology. Such methodology may, but is not required to, be based on applicable codes. The estimates of the reimbursement objective for fee scheduled medical services shall be derived from data on all reimbursements and other amounts paid to providers for fee scheduled medical services provided pursuant to this title during 2014 and 2015, to the extent available.
E. The maximum pecuniary liability of the employer for a fee scheduled medical service that is not included in a Virginia fee schedule when it is provided shall be determined by the Commission. The Commission’s determination of the employer’s maximum pecuniary liability for such fee scheduled medical service shall be effective until the Commission sets a maximum fee for the fee scheduled medical service and incorporates such maximum fee into an adjusted Virginia fee schedule adopted pursuant to subsection D. If the fee scheduled medical service is not included in a Virginia fee schedule because it is:
1. A new type of technology, including an implantable medical device or item of medical equipment, that is supplied by a third party, provided that such technology has been cleared or approved by the federal Food and Drug Administration (FDA) prior to the date of the provision of the medical service, the employer’s maximum pecuniary liability shall not exceed 130 percent of the provider’s invoiced cost for such device, as evidenced by a copy of the invoice. If the new type of technology has not been cleared or approved by the FDA prior to such date, then the provider shall not be entitled to payment or reimbursement therefor unless the employer or its insurer agree; or
2. A new type of procedure that has not been assigned a billing code, the employer’s maximum pecuniary liability shall not exceed 80 percent of the provider’s charge for the service based on the provider’s charge master or schedule of fees, provided the employer and the provider mutually agree to the provision of such procedure.
1. Provide public access to information regarding the Virginia fee schedules for medical services, by categories of providers of fee scheduled medical services and for each medical community, through the Commission’s website. No information provided on the website shall be provider-specific or disclose or release the identity of any provider; and
G. The Commission’s retaining of a firm with nationwide experience and actuarial expertise in the development of workers’ compensation fee schedules to assist the Commission in developing the Virginia fee schedules pursuant to subsections C and D shall be exempt from the provisions of the Virginia Public Procurement Act (§ 2.2-4300 et seq.), provided the Commission shall issue a request for proposals that requires submission by a bidder of evidence that it satisfies the conditions for eligibility established in this subsection and in subdivision C 4. Records and information relating to payments or reimbursements to providers that is obtained by or furnished to the Commission by such firm or any other person shall (i) be for the exclusive use of the Commission in the course of the Commission’s development of fee schedules and related regulations and (ii) shall remain confidential and shall not be subject to the provisions of the Virginia Freedom of Information Act (§ 2.2-3700 et seq.).
H. When the total charges of a hospital or Type One teaching hospital, based on such provider’s charge master, for inpatient hospital services covered by a DRG code exceed the charge outlier threshold, then the Commission shall establish the maximum fee for such scheduled inpatient hospital services at an amount equal to the total of (i) the maximum fee for the service as set forth in the applicable fee schedule and (ii) 80 percent of the provider’s total charges for the service in excess of the charge outlier threshold. The charge outlier threshold for such services initially shall equal 150 percent of the maximum fee for the service set forth in the applicable fee schedule; however, the Commission, in consultation with the firm retained pursuant to subdivision C 4, is authorized on a biennial basis to decrease such percentage if it finds that the number of such claims for which the total charges of the hospital or Type One teaching hospital exceed the charge outlier threshold is less than five percent or to increase such percentage if such number is greater than 10 percent of all such claims.
N. The CPT code and National Correct Coding Initiative rules, as in effect at the time a medical service was provided to the claimant, shall serve as the basis for processing a health care provider’s billing form or itemization for such items as global and comprehensive billing and the unbundling of medical services. Hospital in-patient medical services shall be coded and billed through the International Statistical Classification of Diseases and Related Health Problems as in effect at the time the medical service was provided to the claimant.
Code 1950, § 65-86; 1968, c. 660, § 65.1-89; 1991, c. 355; 2014, c. 670; 2015, c. 456; 2016, cc. 279, 290.
If you’re reading this for anything important, you should double-check its accuracy—read § 65.2-605 on the official Code of Virginia website.
Stephen J. Leibovic, MD v. San Juanito Melchor,etc (COA, 03/06/01)
. . . that the . . .
. . . Fredericksburg Orthopaedic Associates v. Fredericksburg . . . (COA, 05/14/13)
. . . compensation patients is . . .
NAT. LINEN SER./NAT. SERVICE v. Parker (COA, 09/05/95)
. . . for by the injured person? (Code of Virginia, § 65.2-605) . . .
CERES MARINE TERMINALS v. Armstrong (COA, 03/06/12)
. . . treatment for the injury. However, under Code § 65.2-605, "[t]he pecuniary liability of the . . .
Town & Country Hospital, LP v. Reginald Davis (COA, 04/21/15)
. . . but located outside . . .
Miller v. POTOMAC HOSP. FOUNDATION (COA, 12/11/07)
. . . 's medical bills in accordance with Code § 65.2-605 by failing to raise such defense to the . . .
Amoco Foam Products Company v. Essie L. Johnson (COA, 12/30/97)
. . . original industrial injury"). See also Code . . .
. . . Virginia Polytechnic Institute & State . . . (COA, 12/13/05)
. . . treatment is paid for by the injured person.” Code § 65.2-605. Whenever an employee . . .
. . . Julio Emilio Posada v. Virginia Polytechnic Institute & . . . (COA, 12/13/05)
SB367: Workers' compensation; employer liability for medical services. (failed)
HB1326: Workers' compensation; medical services. (failed)
HB1612: Workers' compensation; fee schedule for medical care services and prompt payment. (failed)
HB2160: Virginia Workers' compensation; limitations period and balance billing. (failed)
HB2206: Workers' compensation insurance; payments to providers of health care services. (failed)
HB1017: Workers' compensation; cost and payment for medical services. (failed)
HB1058: Workers' compensation; payments for medical services, liability of employer. (failed)
HB1083: Workers' compensation; cost and payment for medical services, claims filed with Commission, etc. (passed)
HB946: Workers' compensation; fee schedule for medical care services, prompt payment of bills. (failed)
HB1820: Workers' compensation; pecuniary liability of the employer for medical services, report. (passed)
HB378: Workers' compensation; fee schedules for medical and legal services. (passed)
HB1571: Workers' compensation; fees for medical services. (passed)
HB558: Workers' Compensation; employer's liability for medical services provided outside the Commonwealth. (passed)
SB227: Virginia Workers' Compensation Commission; review and adjust fee schedules annually. (failed)
§ 65.2-605.1 Prompt payment; limitation on claims