Virginia Workers' Compensation Commission

Medical Fee Services Newsletter

Q3 2024

Regulatory Focus - 65.2-605.D

The Virginia Workers’ Compensation Commission shall review Virginia fee schedules during the year that follows the ​transition date and biennially thereafter and, if necessary, adjust the Virginia fee schedules in order to address (i) ​inflation or deflation as reflected in the medical care component of the Consumer Price Index for All Urban ​Consumers (CPI-U) for the South as published by the Bureau of Labor Statistics of the U.S. Department of Labor; (ii) ​access to fee scheduled medical services; (iii) errors in calculations made in preparing the Virginia fee schedules; and ​(iv) incentives for providers.

The Commission shall not adjust a Virginia fee schedule in a manner that reduces fees on an existing schedule unless ​such a reduction is based on deflation or a finding by the Commission that advances in technology or errors in ​calculations made in preparing the Virginia fee schedules justify a reduction in fees.

Greetings from the Manager

The Medical Fee Services Department is in the early stages of the MFS Biennial year review of the schedules. In ​addition to establishing and maintaining medical fee schedule quality standards for the Virginia Workers’ ​Compensation Commission, the department also responds to the many comments and inquiries from healthcare ​providers, employers, insurance companies, third-party administrators, and other stakeholders. Your comments and ​inquiries continue to provide valuable input into the Virginia experience and is integral to the biennial review process.

For this edition, I wanted to highlight key stages in the MFS biennial review process: stakeholder issue submission and ​the formal review process, roles and responsibilities of the Regulatory Advisory Panel, Commission biennial review ​timeline, and Biennial Review FAQs.

Best Regards,

Dr. Drema Thompson

MFS Issue Submission and Review

• The MFS Department compiles the various issues (Virginia experience) that are communicated by stakeholders ​during the period between each MFS effective year.
  
• As applicable, reported issues are forwarded to the Actuarial Firm to review and provide feedback.
  
• Summary of the issue and any additional information is presented to the Commission and Regulatory Advisory ​Panel for review.
  
• The Regulatory Advisory Panel provides recommendations to the Commission for issues.
  
• The issue and recommendation are reviewed for potential impacts during the biennial review year.
  
• If applicable adjustments are made to the appropriate schedule or ground rule.
  

For issue submissions, see ways to contact us below.

Regulatory Advisory Panel Roles and ​Responsibilities § 65.2-605. (F) (2)

On March 22 2016, a motion was approved for the establishment of a 10-member Regulatory Advisory Panel for the ​development of the medical fee schedules. The Regulatory Advisory group is a 10-member panel of stakeholders ​representing (i) the American Insurance Association; (ii) the Property and Casualty Insurers Association of America; (iii) ​the Virginia Self-Insurers Association, Inc.; (iv) the Medical Society of Virginia; (v) the Virginia Hospital and Healthcare ​Association; (vi) a Type One teaching hospital; (vii) the Virginia Orthopaedic Society; (viii) the Virginia Trial Lawyers ​Association; (ix) a group self-insurance association representing employers; and (x) a local government group self-​insurance pool formed under Chapter 27 of Title 15.2. On 07/2/2018, motion approved, the Regulatory Advisory Panel ​would continue post-schedule development and implementation. The primary roles and responsibilities of the ​Regulatory Advisory Panel includes:

• Continued collaboration regarding fee schedule impacts.
  
• Educating the public within the respective areas of impact.
  
• Soliciting feedback of the impacts on the workers’ compensation system to inform recommendations.
  
• Providing recommendations to the Commission in the review of the schedules and accompanying Ground ​Rule documentation.
  

Commission Biennial Review Communications

The Medical Fee Schedule Review Timeline will be located on the Commission website and is your source for the most ​up-to-date ​information regarding the biennial review process. The timeline provides Commission meeting dates, ​times, and ​includes key milestones and status updates for the various stages of the biennial review.

TBD

January 1, ​2026

Medical Fee Schedule Regulatory Advisory Panel/Oliver Wyman/ Commission Meeting ​for preliminary review of the Virginia experience.

Regulatory Advisory Panel/Oliver Wyman/Commission Meeting for review of preliminary ​schedule updates.

Regulatory Advisory Panel/Oliver Wyman/Commission Meeting to finalize fee schedule updates.

Oliver Wyman forwards preliminary fee schedule and ground rules updates.

Commission meets to approve proposed draft schedule and ground rules update.

Draft 2026 MFS and Ground Rules posted on the Commission website.

Public comment period for proposed fee schedule and ground rules updates.

Regulatory Advisory Panel/Oliver Wyman/Commission Meeting to review public comments.

Commission meets to approve final 2026 MFS and Ground Rules.

Approved 2026 schedules and Ground Rules posted on the Commission website.

Revised regulation published in the Virginia Register of Regulations.

2026 Medical Fee Schedule and Ground Rules become effective.

Medical Fee Schedule Biennial Review Q&A

Q: I am trying to look up a code in the MFS calculator but receive an error stating that the billing code is not ​found. Will these be added to the next schedule?

A: During the Biennial Year Review, codes that are not listed in the current fee schedule may be added to the ​schedules provided there is credible data to define a fee schedule maximum fee value.

• Codes not being listed in the fee schedule does not mean that they are not reimbursable. More information on ​reimbursement for codes not listed in the fee schedule can be located in the Ground Rules Document.
  

Q: Where can I find a comprehensive list of changes made in the 2024 fee schedule?

A: Once the MFS biennial review is finalized, a summary document provides a listing of the specific changes that were ​made during the review and identifies any Ground Rule document updates. For the most recent listing of changes for ​the 2024 MFS, please see the “2024 Medical Fee Schedules Summary of Changes” that is located on the Commission ​website.

Helpful Links

MFS Training Opportunities

Topics below are available in-person or virtually.

Understanding the Nuts and Bolts of the Medical Fee Schedules

• Provides a comprehensive review of the MFS Regulations
  
• Introduces the roles and responsibilities of the Commission and Regulatory Advisory Panel
  
• Explores key MFS schedule data elements
  
• Explains the role of the Ground Rules
  

Impacts and Influences of the Medical Fee Schedules

• Clarifies implications for Providers and Payers
  
• Illustrates the MFS review and maintenance of schedules
  

Medical Fee Schedule Dispute Resolution

• Reviews forms and notices
  
• Gives examples of required documentation
  
• Provides examples of key applicable coding conventions
  
• Discusses MFS exclusions and dispute resolution
  

Breaking down the Administrative Determination

• Reviews the importance of supporting medical records
  
• Explores the administrative decision components
  
• Discusses the process to appeal the decision
  

Medical Provider Inquiry Forms

• Reviews the importance of supporting medical records
  
• Explores the administrative decision components
  
• Discusses the process to appeal the decision
  

MFS Calculator Training

• Review the statutory governance and how it influences Commission Medical Fee Services activities such as the development of the calculator.
• Identify key workers’ compensation system experiences and how they intersect with the Commission’s Medical Fee Services goals.
• Review key considerations in navigating the calculator in order to utilize the tool effectively.
• Review the outcomes for medical service codes and applicable Ground Rule adjustments for maximum fee values.
  

Ways to Contact MFS

Contact the Medical Fee Services Department toll-free at 877-664-2566.

Below are recommendations for the best ways to contact MFS depending on your need.