§ 28-33-7 - Health service provider reimbursement.
SECTION 28-33-7
§ 28-33-7 Health service providerreimbursement. – (a) Any dispute as to the reasonableness of the amount of any charge and/orpayment for medical, dental, or hospital services or for medicines orappliances shall be determined by the workers' compensation court after ahearing, and the decision shall be final; provided, that the director of thedepartment of labor and training, in consultation with the workers'compensation court, and representatives of all appropriate medical disciplinespracticing within the state of Rhode Island, shall establish a schedule ofrates of reimbursement for those medical and dental services, excludingnon-physician hospital charges, which are most often provided to employeesreceiving workers' compensation. The schedule shall be published by thedirector utilizing the Physician's Current Procedure Terminology (CPT) codingsystem as published by the American Medical Association. The director shallupdate and revise the schedule as necessary. In setting the rate ofreimbursement for any service or procedure, the director shall determine, basedupon available data, the ninetieth (90th) percentile of the usual and customaryfee charged by health care providers in the state of Rhode Island and theimmediate surrounding area, and in no case shall the rate of reimbursementexceed that amount. The liability of the employer or insurer for any chargesand/or payment shall be limited to the rates of reimbursement set forth in thisschedule including, but not limited to, charges for opinions on loss of use andmaximum medical improvement; provided, that petitions may be filed in caseswhere the reasonableness of a particular rate is questioned, but the courtshall be limited to a determination as to whether the rate, as applied in thatparticular case, is reasonable. The burden shall be upon the petitioner seekingpayment of the medical bill to establish by a preponderance of the evidencethat the rate, as applied, is unreasonable in light of the peculiar nature ofthe services performed or other circumstances requiring a greater than normalexpertise or expenditure of time or effort in providing the service.
(b) Subject to the provisions of subsection (a) of thissection, disputes other than those covered in § 28-33-9 pertaining tohospitalizations, medical services, appliances, or medicine shall be heard anddetermined by the workers' compensation court in accordance with guidelines andprotocols established by the medical advisory board.
(c) With respect to all complaints and charges ofunprofessional conduct including, but not limited to, unnecessary orinappropriate treatment and any overcharges against any medical care providerbrought to the attention of the workers' compensation court in the performanceof their duties under this title, the court shall report all complaints andcharges to the appropriate board of licensure and discipline.
(d) The chief judge is authorized to establish a health carefee arbitration panel and to establish rules and procedure for the panel tomake binding decisions in any dispute as to the value of health care servicesrendered under this title, and to compensate its members in an amount not toexceed two hundred dollars ($200) per day. The panel shall consist of onephysician appointed by the president of the Rhode Island Medical Society, onephysician who is a member of the Rhode Island Medical Society appointed by themanager of the state workers' compensation insurance fund, and one physicianwho is a member of the Rhode Island Medical Society appointed by the chiefjudge of the workers' compensation court.