New Mexico § 52-4-5 - Fee schedule

§ 52-4-5. Fee schedule

A. The director shall adopt and promulgate regulations establishing a schedule of

maximum charges as deemed necessary for treatment or attendance, service, devices,

apparatus or medicine provided by a health care provider. The rates in the schedules of maximum charges shall not fall below the sixtieth

percentile or above the eightieth percentile of current rates for health care providers. In determining current rates for health care providers, the director shall utilize

a variety of health care provider charges, including the charges of those providers

serving low income, medicare and medicaid patients. B. A health care provider shall be paid his usual and customary fee for services rendered

or the maximum charge established pursuant to Subsection A of this section, whichever

is less. However, in no case shall the usual and customary fee exceed the maximum charge

allowable. C. The fee schedule shall be revised annually by the director. D. No amount in excess of the amount required by Subsection B of this section for

a service shall be paid by the employer, the employer's insurer, the worker, a representative

of the worker or any other person to a health care provider for rendering that service

in connection with an injury or disablement within the purview of the Workers' Compensation

Act or the New Mexico Occupational Disease Disablement Law. E. If it is determined by the person primarily responsible for payment that the charges

of a health care provider exceed the amount established pursuant to Subsection B of

this section or that a health care provider over-utilized or otherwise rendered or

ordered inappropriate health care or health care services, and payment is withheld

on those grounds, the health care provider may appeal to the director regarding that

determination. The director shall establish by regulation procedures for an appeal by a health

care provider. F. The director shall establish an advisory committee that shall: (1) be appointed and serve at the pleasure of the director; (2) consist of members, a majority of whom represent health care providers; (3) reflect the diversity of authorized licensed health care providers available for

workers' compensation and occupational disease disablement cases; (4) assist in establishing the schedules of maximum charges under Subsection A of

this section for any fees that are payable to health care providers; (5) assist the director in adopting regulations for employers' utilization review

procedures and the establishment and conduct of utilization review boards; and (6) report its findings, upon request, to the director and the advisory council on

workers' compensation. G. The schedule of maximum charges specified in this section shall not apply to hospital

charges. The director shall establish a separate schedule of maximum charges for hospital

charges no later than April 1, 1991. H. Nothing in this section shall prevent an employer from contracting with a health

care provider for fees less than the maximum charges allowable.