Medical Fee Services eNews

Q3

2022

Virginia Workers' Compensation Commission

Regulatory Focus

In response to § 65.2-605, the administrative dispute resolution process is external to a Judicial review; provides interpretation for the fee schedule Ground Rules and was adopted by the Commission to define the employer’s maximum liability for fee scheduled medical services when ordered by the Commission.

From MFS Desk

The Medical Fee Services Department establishes and maintains medical fee schedule quality standards for the Virginia Workers’ Compensation Commission. The department provides direction, training and information to the public on the medical fee schedule and related requirements.

This quarterly issue provides a focus on Medical Fee Services Department Administrative Dispute Resolution and highlights key stakeholder inquiries regarding the administrative determination process.

Administrative Dispute Resolution Q&A

Q1

I received my administrative determination. What does it mean if deficiencies have been found?

The administrative review process determines the employer’s maximum liability for the disputed medical services. The determined fee schedule maximum amount is not an order to pay, if a deficiency was found, it means that the payment issued for the medical service is less than the determined maximum fee.

This decision is based exclusively on the information provided by the parties and shall be final and

binding upon the parties 30 days following its issuance unless an appeal is requested.

Answer

I submitted a Medical Fee Schedule dispute request, however the Medical Fee Schedule dispute resolution process is not applicable. Why?

Q2

Answer

There are several reasons that the administrative dispute resolution process may not be applicable. The Commission may reject a Medical Fee Schedule Dispute request when there has been no award entered for the injured worker. While a medical provider may have standing under the Virginia Workers' Compensation Act to pursue a claim even in the absence of an award, the medical provider would have the burden of proving the merits of the claim, including compensability of the underlying accident. The administrative dispute resolution process is not applicable until an award has been entered.

While we do not encourage or discourage medical providers from filing applications to recover medical costs, you may wish to refile your medical fee schedule administrative dispute once an award has been entered on the claim.

Please see the “Did You Know” section below for additional dispute eligibility criteria.

Q3

I submitted a dispute request to the Commission, however, all the issues in the dispute have since been resolved. Does the Commission require additional documentation?

Yes, a letter of withdrawal or evidence of resolution of the disputed amount. You may fax or mail a request stating that all issues have been resolved and you would like to withdraw the dispute. Please include the jurisdiction claim number, date of service and the name of the injured worker.

Answer

Did You Know?

MFS Dispute Eligibility Criteria

• Jurisdiction of the claim must be the state of VA
  

           (For medical services provided at places of service outside of the Commonwealth    

           of Virginia, please refer to the Ground Rules Document for applicability to out-of-

           state medical providers. Applicable to out-of-state medical providers)

• Dates of service are required on or after January 1, 2018
  

           (The date of injury does not influence eligibility)

• Healthcare services cannot be included in the Exclusions list
  

• Applies in the absence of a contract or negotiated agreement
  

MFS Educating the Public

Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a Medical Fee Schedule Dispute Request Form along with supporting documentation to the Medical Fee Services department for administrative review and determination.

If issues in the dispute are not applicable, please include a detailed description of the disputed issues.

Do you have new staff?

Would you like an overview of the medical fee schedules?

Please send your request to: medicalfeeservices@workcomp.virginia.gov

Save the Date

VWC Conference - September 29-30, 2022

VVF Symposium  - September 30, 2022

held in-person at the Greater Richmond Convention Center