An Act To Clarify Usual and Customary Charges under the Workers' Compensation Laws
Maine Legislature, Session 125, LD 1244
Committee Amendment CA_A_S250 (Senate)
Amends: 39-A MRSA §206, 39-A MRSA §208, 39-A MRSA §209, 39-A MRSA §209-A

COMMITTEE AMENDMENT" A ,. to S.P. 365, L.D. 1244. Bill. "An Act To 
Clarify Usual and Customary Charges under the Workers' Compensation Laws" 
Amend the bill by striking out the title and substituting the following: 
'An Act Regarding Payment of Medical Fees in the Workers' Compensation System' 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 39-A MRSA §206, sub-§14, as enacted by PL 1991, c. 885, PL A, §8 and 
affected by § §9 to II, is amended to read: 
14. Employer not liable. An employer is not liable under this Act for charges for 
health care services to an injured employee in excess of those established under section 
W9 209-A, except upon petition as provided. The board shall allow charges in excess of 
those provided under section .;w9 209-A against the employer if the provider satisfactorily 
demonstrates to the board that the services \vere extraordinary or that the provider 
incurred extraordinary costs in treating the employee as compared to those reasonably 
contemplated for the services provided. 
Sec. 2. 39-A MRSA §208, sub-§2, ~E, as enacted by PL 1991, c. 885, Pt. A, §8 
and affected by § §9 to II, is amended to read: 
E. A health care provider may not charge the insurer or self-insurer an amount in 
excess of the fees prescribed in section lO9 209-A for the submission of reports 
prescribed by this section and for the submission of any additional records. 
Sec. 3. 39-A MRSA §209, as amended by PL 2007, c. 240, PI. JJJ, §5 and c. 311, 
§2, is repealed. 
Sec. 4. 39-A MRSA §209-A is enacted to read: 
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COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 365, L.D. 1244 
§209-A. Medical fee schedule 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. 
"Ancillary services and products" means those services and products that are 
necessary but peripheral to the medical procedure. 
B. "Medical fee schedule" means a list of medical procedures and the medical codes 
used and fees charged for those medical procedures. 
2. Medical fee schedule. In order to ensure appropriate limitations on the cost of 
health care services while maintaining broad access for employees to health care 
providers in the State, the board shall adopt rules that establish a medical fee schedule 
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setting the fees for medical and ancillary services and products rendered by individual 
health care practitioners and health care facilities in accordance with the following: 
A. 
The medical fee schedule for services rendered by individual health care 
practitioners must reflect the methodologv underlying the federal Centers for 
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Medicare and Medicaid Services resource-based relative value scale; 
B. The medical fee schedule for services rendered by health care facilities must 
reflect the methodology and categories set forth in the federal Centers for Medicare 
and Medicaid Services severity-diagnosis related group system for inpatient services 
and the methodologies and categories set forth in the federal Centers for Medicare 
and Medicaid Services ambulatory payment classification system for outpatient 
services; and 
C. The medical fee schedule must be consistent with the most current medical coding 
and billing systems, including the federal Centers for Medicare and Medicaid 
Services resource-based relative value scale, severity-diagnosis related group svstem. 
ambulatory payment classification system and healthcare common procedure coding 
svstem: the International Statistical Classification of Diseases and Related Health 
Problems report issued by the World Health Organization and the current procedural 
terminology codes used by the American Medical Association. 
3. 
Annual updates. 
Notwithstanding Title 5, chapter 375, subchapter 2. the 
executive director of the board shall annually update the medical fee schedule developed 
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pursuant to subsection 2. In order to facilitate the update, the executive director annually 
shall obtain from the Maine Health Data Organization the average total payments, 
including professional, facility, ancillary and patient cost-sharing contribution, across all 
providers in the Maine Health Data Organization database for the medical and ancillary 
services and products most commonly rendered during the immediately preceding 
calendar vear under this Part. 
4. Reimbursement rate if medical fee schedule not established or updated. If the 
board fails to adopt rules that establish a medical fee schedule in accordance with 
subsection 2 by December 31, 201 I or the executive director fails to annually update the 
medical fee schedule in accordance with subsection 3, the reimbursement rate for medical 
services is 105% of the private 3rd-party payor average payment rate for the provider or 
the amount agreed to in writing by the provider and the insurance company or self-
insured employer prior to the rendering of service by the provider. For purposes of this 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" A "to S.P. 365, L.D. 1244 
subsection, "reimbursement rate for medical services" means the total payment allowed 
for the medical and ancillary services and products, including any amount to be paid by a 
3rd-party payor and the amount to be paid by the patient to satisfy a copayment, 
deductible or coinsurance obligation. 
5. Periodic updates to the medical fee schedule. In addition to the annual updates 
to the medical fee schedule required by subsection 3, the board shall undertake a 
comprehensive review of the medical fee schedule once every 3 years beginning in 2014. 
The board shall consider the following factors in setting or revising the medical fee 
schedule as required by this section: 
A. 
The private 3rd-party payor average payment rates obtained from the Maine 
Health Data Organization pursuant to subsection 3; 
B. Any material administrative burden imposed on providers by the nature of the 
workers' compensation svstem: and 
C. The goal of maintaining broad access for employees to all individual health care 
practitioners and health care facilities in the State. 
6. Associated services fee schedule. The board shall adopt rules that establish a fee 
schedule or other standards of reimbursement for providers regarding administrative, case 
management, medical and legal and other activities unique to the treatment of injured 
workers in the workers' compensation system. 
7. MaineCare reimbursement. MaineCare must be paid 100% of any expenses 
incurred for the treatment of an injury of an employee under this Title. 
Sec. 5. Rulemaking; report to Legislature. 
The Workers' Compensation 
Board shall adopt rules to establish a medical fee schedule addressing services provided 
by both individual health care practitioners and health care facilities no later than 
December 31, 20 II. Rules adopted pursuant to this section are routine technical rules 
pursuant to the Maine Revised Statutes, Title 5, chapter 375, subchapter 2-A. 
The 
executive director of the board shall report to the Joint Standing Committee on Labor, 
Commerce, Research and Economic Development on the establishment of the medical 
fee schedule required by Title 39-A, section 209-A no later than February 15, 2012.' 
SUMMARY 
The amendment replaces the bill. it directs the Workers' Compensation Board to 
adopt rules to establish a medical fee schedule for services provided under the Maine 
Workers' Compensation Act of 1992 by individual health care practitioners and health 
care facilities based upon the Medicare payment methodologies that are the basis for most 
health care payment systems today. The amendment removes any reference in existing 
workers' compensation law to "usual and customary charge." The amendment requires an 
annual update of the medical billing and coding systems underlying the medical fee 
schedule and requires a more comprehensive review of the medical fee schedule every 3 
years beginning in 2014. It directs the executive director of the Workers' Compensation 
Board to obtain annually from the Maine Health Data Organization the private 3rd-party 
average payment rates across all private payors and all providers in the Maine Health 
Data Organization's database for the most common medical services rendered under the 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" A" to S.P. 365, L.D. 1244 
Maine Workers' Compensation Act of 1992 during the previous year. The amendment 
requires the Workers' Compensation Board to complete its current medical fee 
rulemaking by December 31, 20 II and to report to the Joint Standing Committee on 
Labor, Commerce, Research and Economic Development regarding the status of the 
medical fec schedule not later than February 15,2012. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 05124111 
~ac 
LD 1244 
LR 1769(02) 
An Act To Clarify Usual and Customary Charges under the Workers' Compensation Laws 
Fiscal Note for Bill as Amended by Committee Amendment" An S - 250 
Committee: Labor, Commerce, Research and Economic Development 
Fiscal Note Required: Yes 
Fiscal Note 
Current biennium savings - All funds 
Fiscal Detail and Notes 
Requiring the Workers' Compensation Board to adopt rules to establish a medical fee schedule for services provided 
under the Maine Workers' Compensation Act by individual health care practitioners and health care facilities based on 
the Medicare payment methodologies may result in savings to the state from a reduction in medical fees. 
Additional costs to the Workers' Compensation Board associated with ru!emaking and with conducting the required 
reviews can be absorbed within existing budgeted resources. Any additional costs to the Maine Health Data 
Organization are expected to be minor and can be absorbed within existing budgeted resources. 
LR 1769(02) - Fiscal Note - Page I of I