Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › BILLING AND REIMBURSEMENT RULES › Section 20-2-I - GENERAL PROVISIONS

Current through June 25, 2024
A.
Maximum
				Allowable Reimbursement (MAR).
Unless the payer and provider have a
				separate fee contract which provides for a different level of reimbursement,
				the maximum allowable reimbursement for health care services shall be the
				lesser of (a) the provider's total billed charge, or (b) the maximum specific
				fee established by the Fee Schedule. Items or services or procedures which do
				not have a maximum specific fee established by this Fee Schedule shall be
				reimbursed at the usual and customary fee as defined in this Fee Schedule, and
				in such cases, the maximum allowable reimbursement shall be the lesser of (1)
				the provider's total billed charge, or (2) the usual and customary fee as
				defined by this Fee Schedule.
If this Fee Schedule does not establish a maximum specific
				  fee for a particular service or procedure, and a usual and customary rate
				  cannot be determined because the FH Benchmarks products do not contain a fee
				  for same, then the maximum allowable reimbursement shall be equal to the
				  national Medicare allowance plus thirty percent (30%). In the absence of an
				  established Medicare value, and assuming none of the above provisions apply,
				  the maximum allowable reimbursement shall be eighty percent (80%) of the
				  provider's total billed charge. Any new codes will be assigned values and
				  posted on the MWCC website annually, or as needed.
B.
Separate Fee Contract.
An
				employer/payer may enter into a separate contractual agreement with a medical
				provider regarding reimbursement for services provided under the provisions of
				the Mississippi Workers' Compensation Law, and if an employer/payer has such a
				contractual agreement with a provider designed to reduce the cost of workers'
				compensation health care services, the contractual agreement shall control as
				to the amount of reimbursement and shall not be subject to the maximum
				allowable reimbursement otherwise established by the Fee Schedule. However, all
				other rules, guidelines and policies as provided in this Fee Schedule shall
				apply and shall be considered to be automatically incorporated into such
				agreement.
1.
Repricing
				Agreements.
Payers and providers may voluntarily enter into repricing
				agreements designed to contain the cost of workers' compensation health care
				after the medical care or service has been provided, and in such case, the
				reimbursement voluntarily agreed to by the parties shall control to the
				exclusion of the Fee Schedule. However, the time spent by the payer and
				provider attempting to negotiate a post-care repricing agreement does not
				extend the time elsewhere provided in this Fee Schedule for billing claims,
				paying claims, requesting correction of an incorrect payment, requesting
				reconsideration, seeking dispute resolution, or reviewing and responding to
				requests for correction or reconsideration or dispute resolution. In addition,
				applicable interest and penalties related to late billing and/or late payment
				shall continue to accrue as otherwise provided. Efforts to negotiate a
				post-care repricing agreement do not justify late billing or payment, and
				either party may seek further relief in accordance with the rules provided
				herein should billing or payment not be made within the time otherwise due
				under these rules. No party shall be obligated to negotiate or enter into a
				repricing agreement of any kind whatsoever.
No party, in attempting to negotiate a repricing or other
				  post treatment price reduction agreement, shall state or imply that consent to
				  such an agreement is mandatory, or that the failure to enter into any such
				  agreement may result in audit, delay of payment, or other adverse consequence.
				  If the MWCC determines that any party, or other person in privity therewith,
				  has made such false or misleading statements in an effort to coerce another
				  party's consent to a repricing or other price reduction agreement outside the
				  Fee Schedule, the MWCC may refer the matter to the appropriate authorities to
				  consider whether such conduct warrants criminal prosecution under §
											71-3-69
				  of the Law.
This statute declares that any false or misleading statement
				  or representation made for the purpose of wrongfully withholding any benefit or
				  payment otherwise due under the terms of the Workers' Compensation Law shall be
				  considered a felony. In addition, the MWCC may levy a civil penalty in an
				  amount not to exceed ten thousand dollars ($10,000.00) if it finds that payment
				  of a just claim has been delayed without reasonable grounds, as provided in
				  §
											71-3-59(2)
				  of the Law.