§ 97-26. Fees allowed for medical treatment; malpractice of physician.
§ 97‑26. Fees allowedfor medical treatment; malpractice of physician.
(a) Fee Schedule. TheCommission shall adopt a schedule of maximum fees for medical compensation,except as provided in subsection (b) of this section, and shall periodicallyreview the schedule and make revisions pursuant to the provisions of thisArticle.
The fees adopted by theCommission in its schedule shall be adequate to ensure that (i) injured workersare provided the standard of services and care intended by this Chapter, (ii)providers are reimbursed reasonable fees for providing these services, and(iii) medical costs are adequately contained.
Prior to adoption of a feeschedule, the Commission shall publish notice of its intent to adopt theschedule in the North Carolina Register and hold a public hearing. Thepublished notice shall include the location, date and time of the publichearing, the proposed effective date of the fee schedule, the period of timeduring which the Commission will receive written comments on the proposedschedule, and the person to whom comments and questions should be directed. Inaddition to publication in the North Carolina Register, the notice may bemailed to parties who have requested notice of the fee schedule hearing. Thepublic hearing shall be held no earlier than 15 days after the publication ofthe notice. The Commission shall receive written comments for at least 30 daysor until the date of the public hearing, whichever is later, after which theCommission may adopt the fee schedule.
The Commission may considerany and all reimbursement systems and plans in establishing its fee schedule,including, but not limited to, the State Health Plan for Teachers and StateEmployees (hereinafter, "State Plan"), Blue Cross and Blue Shield,and any other private or governmental plans. The Commission may also considerany and all reimbursement methodologies, including, but not limited to, the useof current procedural terminology ("CPT") codes, diagnostic‑relatedgroupings ("DRGs"), per diem rates, capitated payments, and resource‑basedrelative‑value system ("RBRVS") payments. The Commission mayconsider statewide fee averages, geographical and community variations inprovider costs, and any other factors affecting provider costs.
An appeal from a decision ofthe Commission establishing a fee schedule, by any party aggrieved thereby,shall be to the North Carolina Court of Appeals. The decision of the Commissionshall be affirmed if supported by substantial evidence. For the purposes of theappeal, the Commission is a party.
(b) Hospital Fees. Eachhospital subject to the provisions of this subsection shall be reimbursed theamount provided for in this subsection unless it has agreed under contract withthe insurer, managed care organization, employer (or other payor obligated toreimburse for inpatient hospital services rendered under this Chapter) toaccept a different amount or reimbursement methodology.
Except as otherwise providedherein, payment for medical treatment and services rendered to workers'compensation patients by a hospital shall be a reasonable fee determined by theCommission. Effective September 16, 2001, through June 30, 2002, the fee shallbe the following amount unless the Commission adopts a different fee schedulein accordance with the provisions of this section:
(1) For inpatienthospital services, the amount that the hospital would have received for thoseservices as of June 30, 2001. The payment shall not be more than a maximum ofone hundred percent (100%) of the hospital's itemized charges as shown on theUB‑92 claim form nor less than the minimum percentage for payment ofinpatient DRG claims that was in effect as of June 30, 2001.
(2) For outpatienthospital services and any other services that were reimbursed as a discount offof charges under the State Plan as of June 30, 2001, the amount calculated bythe Commission as a percentage of the hospital charges for such services. Thepercentage applicable to each hospital shall be the percentage used by theCommission to determine outpatient rates for each hospital as of June 30, 2001.
(3) For any otherservices, a reasonable fee as determined by the Industrial Commission.
Notwithstanding any otherprovisions of law, the Commission's determination of payment rates under thissubsection shall:
(1) Comply with theprocedures for adoption of a fee schedule established in G.S. 97‑26(a);
(2) Include publicationof the proposed payment rate, and a summary of the data and calculations onwhich the rate is based at least 90 days before the proposed effective date;
(3) Be subject to thedeclaratory ruling provisions of G.S. 150B‑4; and
(4) Be deemed toconstitute a final permanent rule under Article 2A of Chapter 150B for purposesof judicial review under Article 4 of that Chapter.
A hospital's itemized chargeson the UB‑92 claim form for workers' compensation services shall be thesame as itemized charges for like services for all other payers.
(c) MaximumReimbursement for Providers Under Subsection (a). Each health care providersubject to the provisions of subsection (a) of this section shall be reimbursedthe amount specified under the fee schedule unless the provider has agreedunder contract with the insurer or managed care organization to accept adifferent amount or reimbursement methodology. In any instance in which neitherthe fee schedule nor a contractual fee applies, the maximum reimbursement towhich a provider under subsection (a) is entitled under this Article is theusual, customary, and reasonable charge for the service or treatment rendered.In no event shall a provider under subsection (a) charge more than its usualfee for the service or treatment rendered.
(d) Information toCommission. Each health care provider seeking reimbursement for medicalcompensation under this Article shall provide the Commission informationrequested by the Commission for the development of fee schedules and thedetermination of appropriate reimbursement.
(e) When ChargesSubmitted. Health care providers shall submit charges to the insurer ormanaged care organization within 30 days of treatment, within 30 days after theend of the month during which multiple treatments were provided, or within suchother reasonable period of time as allowed by the Commission. If an insurer ormanaged care organization disputes a portion of a health care provider's bill,it shall pay the uncontested portion of the bill and shall resolve disputesregarding the balance of the charges in accordance with this Article or itscontractual arrangement.
(f) Repeating DiagnosticTests. A health care provider shall not authorize a diagnostic testpreviously conducted by another provider, unless the health care provider hasreasonable grounds to believe a change in patient condition may have occurredor the quality of the prior test is doubted. The Commission may adopt rulesestablishing reasonable requirements for reports and records to be madeavailable to other health care providers to prevent unnecessary duplication oftests and examinations. A health care provider that violates this subsectionshall not be reimbursed for the costs associated with administering oranalyzing the test.
(g) DirectReimbursement. The Commission may adopt rules to allow insurers and managedcare organizations to review and reimburse charges for medical compensationwithout submitting the charges to the Commission for review and approval.
(h) Malpractice. Theemployer shall not be liable in damages for malpractice by a physician orsurgeon furnished by him pursuant to the provisions of this section, but theconsequences of any such malpractice shall be deemed part of the injuryresulting from the accident, and shall be compensated for as such.
(i) Resolution ofDispute. The employee or health care provider may apply to the Commission bymotion or for a hearing to resolve any dispute regarding the payment of chargesfor medical compensation in accordance with this Article. (1929, c. 120, s. 26; 1955,c. 1026, s. 3; 1993 (Reg. Sess., 1994), c. 679, s. 2.3; 1995 (Reg. Sess.,1996), c. 548, s. 1; 1997‑145, s. 1; 2001‑410, s. 3; 2001‑413,s. 8.2(a); 2005‑448, s. 5; 2007‑323, s. 28.22A(o); 2007‑345,s. 12.)