803 KAR 25:089. Workers' compensation medical fee schedule for physicians.


      RELATES TO: KRS 342.0011(32), 342.019, 342.020, 342.035

      STATUTORY AUTHORITY: KRS 342.020, 342.035(1), (4)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 342.035(1) requires the commissioner of the Department of Workers' Claims to promulgate administrative regulations to ensure that all fees, charges and reimbursements for medical services under KRS Chapter 342 are limited to charges that are fair, current, and reasonable for similar treatment of injured persons in the same community for like services, where treatment is paid for by general health insurers. KRS 342.035(4) requires the commissioner to promulgate an administrative regulation establishing the workers' compensation medical fee schedule for physicians. Pursuant to KRS 342.035, a schedule of fees is to be reviewed and updated, if appropriate, every two (2) years on July 1. This administrative regulation establishes the medical fee schedule for physicians.


      Section 1. Definitions. (1) "Medical fee schedule" means the 2016 Kentucky Workers’ Compensation Fee Schedule for Physicians.

      (2) "Physician" is defined by KRS 342.0011(32).


      Section 2. Services Covered. (1) The medical fee schedule shall govern all medical services provided to injured employees by physicians under KRS Chapter 342.

      (2) The medical fee schedule shall also apply to other health care or medical services providers to whom a listed CPT code is applicable unless:

      (a) Another fee schedule of the Department of Workers' Claims applies;

      (b) A lower fee is required by KRS 342.035 or a managed care plan approved by the commissioner pursuant to 803 KAR 25:110; or

      (c) An insurance carrier, self-insured group, or self-insured employer has an agreement with a physician, medical bill vendor, or other medical provider to provide reimbursement of a medical bill at an amount lower than the medical fee schedule.


      Section 3. Fee Computation. (1) The appropriate fee for a procedure covered by the medical fee schedule shall be obtained by multiplying a relative value unit for the medical procedure by the applicable conversion factor; and

      (2) The resulting fee shall be the maximum fee allowed for the service provided.


      Section 4. (1) A physician or healthcare or medical services provider located outside the boundaries of Kentucky shall be deemed to have agreed to be subject to this administrative regulation if it accepts a patient for treatment who is covered under KRS Chapter 342.

      (2) Pursuant to KRS 342.035, medical fees due to an out-of-state physician or healthcare or medical services provider shall be calculated under the fee schedule in the same manner as for an in-state physician.


      Section 5. Incorporation by Reference. (1) "2016 Kentucky Workers' Compensation Fee Schedule for Physicians", May 12, 2016edition, is incorporated by reference.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department of Workers' Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. (21 Ky.R. 1603; eff. 2-9-1995; 23 Ky.R. 1750; 2485; eff. 12-12-1996; 25 Ky.R. 915; 1362; eff. 11-18-1998; 28 Ky.R. 1226; eff. 1-14-2002; 32 Ky.R. 747; eff. 1-6-2006; 35 Ky.R. 404, eff. 12-5-2008; 37 Ky.R. 1078 1492; eff. 3-4-2011; 40 Ky.R. 1907; 2304; eff. 6-6-2014; 43 Ky.R. 28, 404; eff. 10-7-2016.)