Arkansas Administrative Code › Agency 099 - Arkansas Workman's Compensation › Rule 099.00.00-001 - Rule 30 - Medical Cost Containment Program

Current through Register Vol. 49, No. 6, June, 2024
I.
GENERAL PROVISIONS
Pursuant to Ark. Code Ann. §
								11-9-517
			 (Repl. 1996) the following rule is hereby established in order to implement a
			 medical cost containment program.
A.
Scope
1. This rule does all of
		  the following:
a. Establishes procedures by
		  which the employer shall furnish, or cause to be furnished, to an employee who
		  receives a personal injury arising out of and in the course of employment,
		  reasonable and necessary medical, surgical, and hospital services and
		  medicines, or other attendance or treatment recognized by the laws of the state
		  as legal, when needed. The employer shall also supply to the injured employee
		  dental services, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing
		  apparatus, and other appliances necessary to cure, so far as reasonably and
		  necessarily possible, and relieve from the effects of the injury.
b. Establishes schedules of maximum fees by a
		  health facility or health care provider for such treatment or attendance,
		  service, device, apparatus, or medicine.
c. Establishes procedures by which a health
		  care provider shall be paid the lesser of (1) the provider's usual charge, or
		  (2) the maximum fee established under this rule, or (3) the MCO/PPO contracted
		  price, where applicable.
d.
		  Provides for the identification of utilization of health care and health
		  services above the usual range of utilization for such services, based on
		  medically accepted standards, and provides for acquiring by a carrier and by
		  the Medical Cost Containment Division (MCCD) of the necessary records, medical
		  bills, and other information concerning any health care or health service under
		  review.
e. Establishes a system for
		  the evaluation by a carrier of the appropriateness in terms of both the level
		  of and the quality of health care and health services provided to injured
		  employees, based upon medically accepted standards.
f. Authorizes carriers to withhold payment
		  from, or recover payment from, health facilities or health care providers which
		  have made excessive charges or which have required unjustified and/or
		  unnecessary treatment, hospitalization, or visits.
g. Provides for the review by the Commission
		  of the records and medical bills of any health facility or health care provider
		  which has been determined not to be in compliance with this rule or to be
		  requiring unjustified and/or unnecessary treatment, hospitalization or office
		  visits.
h. Establishes that when a
		  health care facility or health care provider provides health care or health
		  care service that is not usually associated with, is longer in duration than,
		  is more frequent than, or extends over a greater number of days than that
		  health care or service usually does with the diagnosis or condition for which
		  the patient is being treated, the health care provider may be required by the
		  carrier to explain the necessity in writing.
i. Provides for the implementation of the
		  MCCD review and decision responsibility. The rule and definitions are not
		  intended to supersede or modify the workers' compensation laws, the
		  administrative rules of the Commission, or court decisions interpreting the
		  laws or the Commission's administrative rules.
j. Provides for the certification of carriers
		  determined to be in compliance with the criteria and standards established by
		  this rule in their utilization review of services and charges by health care
		  facilities and health care providers
k. Establishes maximum fees for
		  depositions/witnesses.
I.
		  Establishes maximum fees for medical reports.
m. Provides for uniformity of billing for
		  provider services.
n. Establishes
		  the effective date for implementation of Rule
		  30.
o. Adopts by reference as part of this rule
		  the Medical Fee Schedule and any amendments to that fee schedule.
p. Establishes procedures for balance
		  billing.
q. Establishes procedures
		  for reporting of medical claims.
r.
		  Establishes procedures for obtaining medical services by out-of-state
		  providers.
s. Establishes
		  procedures for preauthorization of nonemergency hospitalizations, transfers
		  between facilities, and outpatient services expected to exceed $1000.00 in
		  billed charges for a single date of service by a provider. (See Arkansas
		  Workers' Compensation Commission inpatient Hospital Fee Schedule Part
		  III.)