Employees who are injured during the course of employment, or who suffer from work-related mental or emotional disabilities, as well as occupational diseases, are eligible for workers' compensation benefits. These benefits include medical and hospital services, medically necessary equipment and prescribed drugs, weekly compensation for lost income during the period the employee cannot work, and vocational and rehabilitation services.
Three state agencies in Massachusetts have key roles in the administration and delivery of services under workers' compensation:
- Department of Industrial Accidents under the Department of Labor and Workforce Development (DLWD)
- Division of Insurance under the Executive Office of Consumer Affairs (EOCA)
- Division of Health Care Finance and Policy under the Executive Office of Health and Human Services (EOHHS)
The Massachusetts Workers' Compensation Advisory Council (WCAC) is mandated to monitor, recommend, give testimony and report on all aspects of the workers' compensation system and issues yearly reports that evaluate operations and supply independent analysis of the Massachusetts system.
Frequently Asked Questions
The Division of Health Care Finance and Policy (Division) has statutory authority under M.G.L. c. 152, s. 13 and c. 118G to establish rates of payment for hospitals and health care providers providing services covered by insurers and other purchasers under M.G.L. c. 152, the Workers' Compensation Act.
1. Are insurers and other purchasers required to use these established rates?
No. Under M.G.L. c. 152, s. 13, the insurer, the employer, and the health care service provider are permitted to agree upon different rates.
2. What is the role of the Division regarding workers' compensation?
The Division sets rates of payment for hospitals, physicians and other health care providers. The Division does not oversee medical necessity or determine clinical appropriateness of procedures and services rendered. These program policies are under the jurisdiction of the Department of Industrial Accidents (DIA) located at 1 Congress Street, Suite 100, Boston, Massachusetts 02114; 617-727-4900.
3. What regulations govern payment for health care services under workers' compensation?
The Division regulations that govern workers' compensation rates are:
- 114.1 CMR 41.00, Rates of Payment for Services Provided to Industrial Accident Patients by Hospitals. In this regulation you will find the rules and methodologies for paying Massachusetts hospitals.
- 114.3 CMR 40.00, Rates for Services Under M.G.L. c. 152, Workers' Compensation Act. Referred to as the "fee schedule," this regulation contains 12 separate sections that list rates used to pay for health care services delivered by ambulatory provider types, such as physicians and physical therapists.
4. How do I obtain the regulations mentioned above? Is there a charge for resource documents?
You may download the documents by clicking on the above links. If you do not wish to download these documents from the Division's web site, you may contact the Public Records Officer at DHCFP for information and prices of documents. The Public Records Officer can be reached via email at email@example.com.
5. Where can I find current payment information for hospitals?
List of Payment on Account Factors (PAFs) for acute care and non-acute care hospitals: Hospital PAFs.
Payments for restorative services provided by the facilities in the attached list are made under 114.1 CMR 41.00 rather than 114.3 CMR 40.00:
Hospital owned and/or operated sites of restorative services established prior to July 1, 1993 (Excel) .
6. How do I pay for services that are not contained in the Workers' Compensation fee schedule and for prescription pharmacy rates? How can I obtain the current rates?
Below is a listing of services and the regulations governing their rates of payment. For current rate information, please click on the link.
- Abortion and Sterilization Services, 114.3 CMR 13.00
- Adult Day Health, 114.3 CMR 10.00
- Ambulance Services, 114.3 CMR 27.00
- Chronic Maintenance Dialysis Treatment and Home Dialysis Supplies, 114.3 CMR 37.00
- Hearing Aid Dispensers, 114.3 CMR 23.00
- Home Health Services, 114.3 CMR 50.00
- Hospice Services, 114.3 CMR 43.00
- Independent Living Services for the Personal Care Attendant Program, 114.3 CMR 9.00
- Outpatient Tuberculosis Control Services, 114.3 CMR 8.00
- Prescribed Drugs, 114.3 CMR 31.00 ; Informational Bulletin #04-11
- Psychiatric Day Treatment, 114.3 CMR 7.00
- Rates for Community Health Centers, 114.3 CMR 4.00 Regulations
- Rates of Payment for Mental Health Services Provided in Community Health Centers and Mental Health Centers, 114.3 CMR 6.00 Regulations
- Residential Care Facilities: <u>Rest Homes, 114.2 CMR 4.00</u>
- Standard Payments to Nursing Facilities <u>, 114.2 CMR 6.00</u>
- Substance Abuse, 114.3 CMR 46.00
- Vision Care Services and Ophthalmic Materials, 114.3 CMR 15.00
7. Why are Pharmacy payments for industrial accidents under a different regulation?
The Division uses the same methods to price prescribed drugs for workers' compensation claims as for Medicaid. Therefore, amendments to 114.3 CMR 40.00 refer to the Prescribed Drugs regulation, 114.3 CMR 31.00. See also, Informational Bulletin #04-11.
8. How do insurers determine jurisdiction? Are out-of-state providers required to accept medical rates set by the Division under Massachusetts law?
The DIA Reviewing Board ruled in Tedeschi v. S&F Concrete, 6 Mass. Workers' Comp. Rep. 120 (1992) that out-of-state providers are bound by the rates set by the Division. Since other jurisdictional questions on coverage are highly dependent on the facts, you may wish to consult with your attorney about your particular situation.
9. Some employers, in order to keep their insurance premiums low or unchanged, would prefer to pay for a worker's injury rather than report it to the employer's workers' compensation carrier. Is this practice legal in Massachusetts?
No. M.G.L. c. 152, s. 6, prohibits this practice in Massachusetts. You should consult DIA if you have questions regarding this issue or visit the DIA website at Department of Industrial Accidents - Labor and Workforce Development.
10. What is the role of PPA, HMO, and MCO agreements?
Preferred Provider Agreements (PPAs) are governed by 211 CMR 51.00, promulgated by the Division of Insurance (DOI). Employers with a PPA are allowed to require that the injured worker be initially assessed by a provider who participates in the PPA. Injured workers have the right to choose treating providers outside of Health Maintenance Organization (HMO) and Managed Care Organization (MCO) plans. Limitations on an injured worker's provider choice apply only to the first scheduled visit in these plans. (see M.G.L. c. 152, s. 30, which is posted on the Department of Industrial Accidents web site.)
11. Do workers' compensation rates apply to medical services for police and firefighters?
Police and firefighters are covered by M.G.L. c. 41, s. 100, which allows cities and towns to pay the "reasonable" medical expenses of police and firefighters for work-related health problems. Cities and towns utilize other governmental purchaser rate levels for this special group. Contact DHCFP's Pricing Group at (617) 988-3206 for questions regarding police and firefighters.
12. Can the employee/worker be billed for balances and/or in addition to the rates set by DHCFP?
No. Under M.G.L. c. 152, s. 13(1), an employee is not liable for amounts in excess of the rates set by the DHCFP. Providers that have received less than they believe they are entitled to may file a third-party lien (Form 115) under the direction and administration of DIA.
13. If the procedure code isn't listed in regulation 114.3 CMR 40.00, how should the provider be paid? What about a hospital outpatient or clinic setting?
For certain types of service, Durable Medical Equipment and ambulatory surgery for example, the regulation directs the reader to another source to determine a rate of payment. For other services the procedure is treated as an Individual Consideration (IC) rate. In a hospital setting, the hospital PAF is applied against charges for unlisted procedures. (See #14 below)
14. What is the procedure for negotiating an Individual Consideration (IC) rate?
A number of the services identified in the fee schedule are listed as IC rates and billed in this fashion. To determine payment for an IC rate, the purchaser must evaluate the claim for services rendered and consider the severity or complexity of the patient's diagnosis or disability, time and degree of skill required, and the policies and payment levels of other purchasers. In a hospital setting, the hospital PAF is applied against charges.
15. What is the procedure for payment to massage therapists and other alternative or complementary therapists?
Massage therapists and other complementary therapists' services are not included in 114.3 CMR 40.00 . If the employer, the insurer, and the provider agree that it is beneficial to the injured worker, then the parties may agree to the service and negotiate a rate and acceptable code(s) for billing purposes.
16. How can one bill for nurses and physician's assistants under 114.3 CMR 40.00?
Currently, Physician's Assistants working under the supervision of a physician may not bill separately for medical procedures. Independent Nurse Practitioners are now eligible providers within the scope of their licensure, and may bill separately. Non-physician providers are subject to a service level reduction in payments and must apply an appropriate modifier for billing purposes.
17. Can chiropractors use radiology codes not listed in the section for chiropractic services?
Yes, chiropractors may bill for radiological services allowed under his/her licensing scope that are listed in the radiology section of the regulation.
18. How are the pre-operative and post-operative ambulatory periods defined?
The Division defines pre-operative and post-operative periods as the duration of the patient's stay at the facility. Apply this definition to Ambulatory Surgical Center (ASC) facility fees and to related surgical procedures performed on the same day. For those procedures identified as inclusive in 114.3 CMR 40.00, the period is extended to include up to two normal post-operative office visits.
19. Why is CPT code 97010 (for the application of hot/cold pack) removed from the current version of the fee schedule?
The Division has found that this is not a commonly payable code by other payers, including Medicare. Therefore, the Division has removed code 97010 for the application of a hot/cold pack as separately payable and advises that if the item is supplied to the patient for home use, the hot/cold pack may be billed under code A9999, Miscellaneous DME supply, and can be paid at I.C. according to guidelines under 114.3 CMR 40.05(6)(f).
20. Are all hospital services payable at the PAF?
No. With few exceptions, the Division establishes rates for comparable services regardless of the setting in which the services were provided. See 114.1 CMR 41.00. The exception is for certain restorative services; certain surgeries that require the immediate availability of inpatient hospital services; and services performed on an emergency basis.
21. Is the insurer/payer required to pay the entire hospital bill for ambulatory services using either the fee schedule or the PAF?
The PAF should be applied to the entire bill for emergent services and ambulatory surgeries that require the availability of inpatient hospital services. If observation services are required and all other billed services are payable using 114.3 CMR 40.00, then the PAF should only be applied to the observation charges.
22. When is an Emergency Department visit not paid at the PAF rate?
Any follow up visit to an emergency room is payable under 114.3 CMR 40.00 and not at the PAF rate under 114.1 CMR 41.00.
23. When is an ambulatory surgery paid at the PAF?
The PAF is used when there is no other payment identified by Medicare for the ASC procedure. First review Medicare's most recent ASC List of Payable Procedures, office-based procedures, and bundled or packaged procedures. If the procedure is not listed in one of these sources then the procedure is payable pursuant to 114.1 CMR 41.04(1)(b).
24. Why is there an additional percentage add-on to acute care hospital bills for the Health Safety Net when hospitals bill according to regulation 114.3 CMR 40.00 ?
The Health Safety Net is funded by several sources, including an assessment on acute care hospitals, a surcharge on hospital payments made by private insurers, the Massachusetts General Fund and other sources. While payments by workers' compensation insurers are exempt from the surcharge on hospital payments, the hospital outpatient charges for services to workers' compensation patients are not exempt and thus subject to the acute hospital assessment. For this reason, Massachusetts acute care hospitals may bill separately an add-on that is calculated as a percentage of the published charges for any services subject to payment using the fee schedule. Payments for outpatient services at the hospital's PAF are not subject to this add-on. The Division updates the percentage by October 1st of each year based upon the revised hospital uniform allowance. The assessment is not payable to non-acute or out-of-state hospitals.
25. How do I get on your mailing list for rate updates and other information?
Please contact the Division. You will need to submit your name, title, company name, address, telephone number and e-mail address.
26. Whom should I call with additional questions about worker's compensation rates?
- 114.1 CMR 41.00: Rates of Payment for Services Provided to Industrial Accident Patients by Hospital
- 114.3 CMR 40.00: Rates for Service Under M.G.L.c.152, Worker's Compensation Act
The price for a hard copy of the regulation 114.3 CMR 40.00 is $200.00 (including postage). To obtain a hard copy, please send a check payable to the "Commonwealth of Massachusetts" to the DHCFP Public Records Officer.
Health Safety Net Fee
The Division of Health Care Finance and Policy (DHCFP) is revising the Health Safety Net fee in accordance with regulation 114.1 CMR 41.00 Rates of Payment for Services Provided to Industrial Accident Patients by Hospitals.
The percentage will remain at .8%, and will be effective for services rendered on or after October 1, 2012 and may be added to acute hospital charges in accordance with 114.1 CMR 41.04(1)(c). This additional percentage is applied to acute care hospital charges when payments to hospitals are based upon the ambulatory fees set forth in 114.3 CMR 40.00 (this includes the separate hospital rates for restorative services and ambulatory surgical facility fees.)
Please note that the amount differs from the percentage hospitals are assessed under 114.6 CMR 14.00 "Health Safety Net Payments and Funding” that is not applicable to workers’ compensation carriers.
For additional background information on this subject, please see frequently asked question 24 above.