The 2018 New York Workers’ Compensation Fee Schedule (The New Fee schedule) governs the 2023 No-Fault billing and reimbursement regulations in New York.
As of April 1, 2019 the New Fee Schedule directives were implemented and therefore applicable to NY No-Fault billing. However, the increased reimbursement rates were not implemented until October 1, 2020. Thus, bills for dates of service October 1, 2020 and later are subject to the new fee schedule’s increased reimbursement rates and should be billed accordingly. Alternatively, bills pre-dating October 1, 2020 are still subject to the old fee schedule reimbursement rates.
It is important to bill the correct fee schedule amount as overbilling will lead to a denial of No-Fault benefits. Additionally, overbilling could lead to the insurance carrier conducting an Examination Under Oath (EUO) of the medical provider who is billing incorrectly. An EUO can delay payment of bills for a considerable amount of time and can end in the permanent denial of claims.
Below are some noteworthy changes that will affect No-Fault providers:
- Maximum reimbursement per day for all providers that are billing for physical modalities has been increased from 8.0 to 12.0 Relative Value Units (RVUs). This number is capped at 12.0 RVUs regardless of what the provider’s specialty is . For example, if a chiropractor bills 6.0 RVUs of physical modality for the same day that a physical therapist has billed 6.0 RVUs that would exhaust the 12 RVU cap for that day.
- Range of motion (ROM) testing and Physical Performance testing has been given a RVU of 0 and thus will not be reimbursed. It is instead considered to be inclusive of a comprehensive exam.
- Radiology Ground Rule number 3(F) states “that imaging studies taken within 7 days of the first imaging study and related to the injury or problem that necessitated the first imaging study, and which could have been reasonably performed at one time, shall be subject to a reduction.”
The New York No-Fault Collections attorneys at the TonaLaw firm have over 50 combined years of experience representing healthcare providers in the collection of No-Fault receivables. The attorneys at TonaLaw have helped clients recover moneys paid for Medicare, Medicaid, Worker’s Compensation, health insurance liens, and lost wages claims for Personal Injury clients whose No-Fault benefits were improperly denied. Further, the attorneys at TonaLaw recover thousands every year in lost wages for their clients. Mr. Tona wrote the “No Stress No-Fault” healthcare provider’s guide to New York State No-Fault insurance which has become an invaluable resource used by hundreds of practitioners across New York.
If you’d like to learn more, send your mailing address to [email protected] to be placed on the waitlist to receive the updated edition of the guide after it is published. To order a copy of the WCB Fee Schedule for your applicable practice areas please click here.
The full text of the changes has been transcribed in its entirety and provided below.
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Workers’ Compensation Board
PROPOSED RULE MAKING
NO HEARING(S) SCHEDULED
Medical Fee Schedules
I.D. No. WCB-27-19-00005-P
PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:
Proposed Action: Addition of Part 329-4; amendment of Part 333, sections 301.3, 329-1.3 and 348.2 of Title 12 NYCRR.
Statutory Authority: Workers’ Compensation Law, sections 13, 117 and 141
Subject: Medical Fee Schedules.
Purpose: Add new providers to the fee schedule.
Text of Proposed Rule: Section 329-1.3 of Title 12 NYCRR is hereby amended to read as follows:
- The medical fee schedule for medical services shall be the Official New York Workers’ Compensation Medical Fee Schedule, updated July 3, 2019, prepared by the board and published by Optumlnsight, which is herein incorporated by reference.
- The Official New York Workers’ Compensation Medical Fee Schedule incorporated by reference herein may be examined at the office of the Department of State, One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the board. Copies may be purchased from Optumlnsight, by writing to Official New York Workers’ Compensation Fee Schedule, PO Box 88050, Chicago, 1L 60680-9920; by telephone at 1-800-464-3649, option 1; or online at www.optum360coding.com keyword New York or click here.
A new part 329-4 is hereby added to read as follows:
Part 329-4 Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule
- cl
- 329-4.1 Application
- The fee schedule applicable to acupuncture services shall be the acupuncture fee schedule in effect on the date on which the acupuncture services were rendered, regardless of the date of accident.
- The fee schedule applicable to physical therapy and occupational therapy services shall be the physical therapy and occupational therapy fee schedule in effect on the date on which the physical therapy or occupational therapy services were rendered, regardless of the date of accident.
- 329-4.2 Acupuncture and physical therapy and occupational therapy fee schedule; incorporation by reference
- The acupuncture fee schedule for acupuncture services shall be the Official New York Workers· Compensation Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule, created July 3, 2019 prepared by the Board and published by Optumlnsight, which is herein incorporated by reference.
- The physical therapy and occupational therapy fee schedule for physical therapy and occupational therapy services shall be the Official New York Workers’ Compensation Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule, created July 3, 2019, prepared by the Board and published by Optumlnsight, which is herein incorporated by reference.
- The Official New York Workers’ Compensation Acupuncture and Physical Therapy Fee Schedule incorporated by reference herein may be examined OJ the office of the Department of State, One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the Board. Copies may be purchased from Optumlnsight, by writing to Official New York Workers’ Compensation Fee Schedule, PO Box 88050, Chicago, IL 60680-9920; by telephone at 1-800- 464-3649, option 1; or online at www.optum360coding.com keyword New York or https://www.optum360coding.com/Product/40508/.
Part 333 of Title 12 NYCRR is hereby amended to read as follows:
- 333.1 Application
The fee schedule applicable to psychological services shall be the behavioral health fee schedule in effect on the date on which the psychological services were rendered, regardless of the date of accident.
- 333.2 Behavioral Health fee schedule; incorporation by reference
- The behavioral health fee schedule for psychology services shall be the official New York Workers· Compensation Behavioral Health Fee Schedule, updated July 3, 2019, prepared by the Board and published by Optumlnsight, which is herein incorporated by reference.
- The Official New York Workers’ Compensation Behavioral Health Fee Schedule incorporated by reference herein may be examined at the office of the Department of State, One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the board. Copies may be purchased from Optumlnsight. by writing to Official New York Workers’ Compensation Fee Schedule, PO Box 88050, Chicago, IL 60680-9920; by telephone at 1-800-464-3641, option 1; or online at www.optum360coding.com keyword New York or https://www.optum360coding.com/Product/40508/.
Section 348.2 of Title 12 NYCRR is hereby amended to read as follows:
- The chiropractic fee schedule for chiropractic services shall be the Official New York Workers’ Compensation Chiropractic Fee Schedule, updated July 3, 2019, prepared by the Board and published by Optumlnsight, which is herein incorporated by reference.
- The Official New York Workers· Compensation Chiropractic Fee Schedule incorporated by reference herein may be examined at the office of the Department of State. One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the board. Copies may be purchased from Optumlnsight, by writing to Official New York Workers’ Compensation Fee Schedule, PO Box 88050, Chicago, IL 60680-9920; by telephone at l-800-464-3649, option l; or online at www.optum360coding.com keyword New York or https://www.optum360coding.com/Product/40508/.
Section 301.3 of Title 12 NYCRR is hereby amended to read as follows:
- 301.3 Section 301.3. Fees for attendance of chiropractors, nurse practitioner, licensed clinical social workers, and psychologists at hearings
Whenever the attendance of the injured employee’s treating or consultant chiropractor, nurse practitioner, licensed clinical social worker, or psychologist at a hearing is required, such chiropractor, nurse practitioner, licensed clinical social worker, or psychologist shall be entitled to an attendance fee of $350. In instances involving special circumstances, the board may fix a fee in an amount greater than the said sum, such increased fee to be commensurate with the circumstances in the particular case. Where the attendance is pursuant to a subpoena issued by the board, the Workers’ Compensation Law judge or any officer of the board so designated by the chair, the attendance fee may be limited to no more than $70.
Text of proposed rule and any required statements and analyses may be obtained from:
Heather MacMaster, Workers’ Compensation Board, 328 State Street, Office of General Counsel, Schenectady, NY 12305, (518) 486-9564, email: [email protected]
Data, views or arguments may be submitted to: Same as above.
Public comment will be received until: 60 days after publication of this notice .
This rule was not under consideration at the time this agency submitted its Regulatory Agenda for publication in the Register.
Regulatory Impact Statement
- Statutory Authority
The statutory authority for this rule comes from §§ 13, 117(1) and 141 of the Workers’ Compensation Law, which allows the Chair to adopt reasonable rules to supplement the provisions of the chapter and the labor law.
- Legislative Objectives
In April 2019, the amendments to section 13-b of the workers’ compensation law were enacted. The new law expanded the categories of providers who may become authorized to treat injured workers to include nurse practitioners, physician assistants, licensed clinical social workers, physical and occupational therapists and acupuncturists.
The proposed amendments add nurse practitioners, physician assistants and licensed clinical social workers to the existing fee schedules and adds a new fee schedule for acupuncturists and physical and occupational therapists. The proposal also provides for testimony fees for nurse practitioners and licensed clinical social workers.
- Needs and Benefits
The bill expanding the list of providers who can become authorized to treat injured workers under the Workers’ Compensation Law will provide more access to different types of providers, and more types of medical care for injured workers. Modifications to the chiropractic fee schedule will align them with fee for similar types of new providers.
The chair is required to set fee schedules for medical providers treating injured workers. Fee schedules also create clarity and reduce billing disputes.
- Costs
The proposed amendments should not impose significant costs. Modifications to the chiropractic fee schedule will align them with fee for similar types of new providers. New providers may wish to purchase the medical fee schedules and interested parties may wish to purchase the Acupuncture and Physical Therapy and Occupational Therapy Fee Schedule. By amending the current fee schedule and combining acupuncture and physical and occupational therapy into a single fee schedule, the Board seeks to minimize any costs.
- Local Government Mandates
There are no specific mandates on local governments as a result of this proposal.
- Paperwork
The proposal does not require any additional paperwork.
- Duplication
There is no duplication of state or federal regulations or standards.
- Alternatives
The Board did not consider any other alternative as the fee schedules are required by statute and this model follows the existing fee schedule framework. Modifications to the chiropractic fee schedule will align them with fee for similar types of new providers. By amending the current fee schedule and combining acupuncture and physical and occupational therapy into a single fee schedule, the Board seeks to minimize any costs.
- Federal Standards
There are no applicable federal standards or regulations related to the proposed amendments.
- Compliance Schedule
The statute becomes takes effect January 1, 2022.
Regulatory Flexibility Analysis
- Effect of rule
The statute expands the list of providers that may become authorized to treat injured workers under the NYS Workers’ Compensation Law. This may mean that new provider types added in the statute that operate as small businesses will now be able to apply for authorization.
- Compliance requirements
The proposal updates existing fee schedules to include new providers and adds fee schedules for acupuncturists and physical and occupational therapists.
- Professional services
It is believed that no professional services will be needed by small businesses or local governments to comply with the proposed regulation.
- Compliance costs
Compliance with the proposed regulations should not impose compliance costs on small businesses or local governments unless such small business are new providers and wish to purchase the fee schedules. In such a case, the fee schedules would facilitate an increase in income due to participation in the workers’ compensation system.
- Economic and technological feasibility
Compliance with the proposed regulations is technologically and economically feasible for small business and local government. No technology is required.
- Minimizing adverse impact
The proposed fee schedules are drafted in accordance with the Board’s current fee schedule. The new providers are being added to the existing fee schedule and acupuncture and physical and occupational therapy are being paired in a single fee schedule to minimize cost.
- Small business and local government participation
The Board will duly consider all public comments received from small businesses or local governments during the public comment period.
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