West Virginia Offices of the Insurance Commissioner 2009 Annual ...

Medical Rates and Plans Unit
The Medical Rates and Plans Division is a unit of Financial Services created on January 1, 2006 with
the integration of workers’ compensation into the Offices of the Insurance Commissioner. The
primary functions of the Medical Rates and Plans Division are based on requirements set forth in WV
Code §23-4-3. These functions are to calculate the workers’ compensation maximum medical
reimbursement rates and evaluate managed health care plans. Secondary responsibilities range from
preparation, analysis and reconciliation of reports to responding to internal and external stakeholder
requests for assistance and education on medical and compensation related issues. To make informed
decisions and recommendations the staff researches various federal, state and local laws including
compensation rules and regulations, medical fee schedules, national standards, and the latest news and
trends of various health insurance carriers and Medicare/ Medicaid. These functions contribute to
workers’ compensation insurance cost containment.
MEDICAL RATES:
In accordance with WV Code the workers’ compensation maximum medical fee schedules are set by
the OIC. These fee schedules and reimbursement rates determine the maximum a carrier/payor can
pay a provider for covered goods and/ or services on behalf of an injured worker outside of a managed
health care plan. The schedules are comprised of thousands of national standard medical codes and
each code has a calculated reimbursement value based on methodology. The Medical Rates and Plans
area of the OIC website allows internal and external customers to view the current OIC maximum fee
schedule methodology.
During the reporting period, in-depth analysis was performed to determine the effects of using existing
WV workers’ compensation fee schedule methodology and the impact of any proposed revisions on
associated medical costs. These complex econometric models were analyzed to enable informed
decisions regarding the need for any formula changes. The existing fee schedule methodology that
follows a more standardized national insurance approach was reviewed, along with those adopted by
various states including those that surround WV. A comparative analysis of a national workers’
compensation bill review survey was also performed. This division looks for opportunities for West
Virginia to benchmark in a national arena. Staff members attended a Centers for Medicare and
Medicaid training opportunity, as well as webinar training to enhance understanding of national
billing, coding, and reimbursement trends.
Based on research, workers’ compensation maximum medical fee schedule methodologies were
developed for nine separate fee schedules. These schedules comprised thousands of codes and fees. It
was determined that the current methodology should be updated for the coming period. These new
schedules were published July 1, 2009 and are effective for dates of service from July 1, 2009 through
June 30, 2010. The Medical Rates and Plans Division continues to focus on customer education with
every contact opportunity.
National codes change frequently throughout the course of every year, and fee schedules require
regular review to ensure insurance market and billing relevance along with impact analysis. The
reference library that supports the medical rate analysis system is updated as needed to assure the most
current information is available for regulatory analysis and stakeholder requests. The Insurance
Commissioner annually provides the legislature a copy of the schedules.
137