Oklahoma § 85-327 - Repealed by Laws 2013, c. 208, § 171, eff. Feb. 1, 2014

§ 85-327. Repealed by Laws 2013, c. 208, § 171, eff. Feb. 1, 2014

NOTE: Prior to repeal, this section was amended by Laws 2013, c.

33, § 1 to read as follows:

A. For the express purpose of reducing the overall cost of medical care

for injured workers in the workers' compensation system by five percent (5%),

the Administrator of the Workers' Compensation Court is hereby directed to

develop a new "Oklahoma Workers' Compensation Medical Fee Schedule" to be

implemented by January 1, 2012. Thereafter, the Administrator shall conduct

a review of the Fee Schedule every two (2) years. The Fee Schedule shall

establish the maximum rates that medical providers shall be reimbursed for

medical care provided to injured workers, including, but not limited to,

charges by physicians, dentists, counselors, hospitals, ambulatory and

outpatient facilities, clinical laboratory services, diagnostic testing

services, and ambulance services, and charges for durable medical equipment,

prosthetics, orthotics, and supplies.

B. Reimbursement for medical care shall be prescribed and limited by the

Fee Schedule as adopted by the Administrator, after notice and public

hearing. The director of the Oklahoma State Employees Group Insurance Board

shall provide the Administrator such information as may be relevant in the

development of the Fee Schedule. The Administrator shall develop the Fee

Schedule in a manner in which quality of medical care is assured and

maintained for injured workers. The Administrator shall give due

consideration to additional requirements for physicians treating an injured

worker under this act, including, but not limited to, communication with

claims representatives, case managers, attorneys, and representatives of

employers, and the additional time required to complete forms for the Court,

insurance carriers, and employers.

Oklahoma Statutes - Title 85. Workers' Compensation

C. In making adjustments to the Fee Schedule, the Administrator shall

use, as a benchmark, the reimbursement rate for each Current Procedural

Terminology (CPT) code provided for in the fee schedule published by the

Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of

Health and Human Services for use in Oklahoma (Medicare Fee Schedule) on

August 6, 2011. For services not valued by CMS, the Administrator shall

establish values based on the usual, customary and reasonable medical

payments to health care providers in the same trade area for comparable

treatment of a person with similar injuries.

1. No reimbursement shall be allowed for any magnetic resonance imaging

(MRI) unless the MRI is provided by an entity that meets Medicare

requirements for the payment of MRI services or is accredited by the American

College of Radiology, the Intersocietal Accreditation Commission or the Joint

Commission on Accreditation of Healthcare Organizations. For all other

radiology procedures, the reimbursement rate shall be the lesser of the

reimbursement rate allowed by the 2010 Oklahoma Fee Schedule or two hundred

seven percent (207%) of the Medicare Fee Schedule.

2. For reimbursement of medical services for Evaluation and Management

of injured employees as defined in the fee schedule adopted by the

Administrator, the reimbursement rate shall not be less than one hundred

fifty percent (150%) of the Medicare Fee Schedule.

3. Any entity providing durable medical equipment, prosthetics,

orthotics or supplies must be accredited by a CMS–approved accreditation

organization. In the event a physician provides durable medical equipment,

prosthetics, orthotics, prescription drugs, or supplies to a patient

ancillary to the patient visit, reimbursement will be no more than ten

percent (10%) above cost.

4. The Administrator shall develop a reasonable stop loss provision of

the Fee Schedule to provide for adequate reimbursement for treatment for

major burns, severe head and neurological injuries, multiple system injuries,

and other catastrophic injuries requiring extended periods of intensive care.

D. The right to recover charges for every type of medical care for

injuries arising out of and in the course of covered employment as defined in

this act shall lie solely with the Workers' Compensation Court and its

administration. When a medical care provider has brought a claim in the

Court to obtain payment for services, a party who prevails in full on the

claim shall be entitled to a reasonable attorney fee.

E. Nothing in this section shall prevent an employer, insurance carrier,

group self-insurance association, or certified workplace medical plan from

contracting with a provider of medical care for a reimbursement rate that is

greater than or less than limits established by the Fee Schedule.

F. A treating physician may not charge more than Four Hundred Dollars

($400.00) per hour for preparation for or testimony at a deposition or court

appearance in connection with a claim covered by the Workers' Compensation

Code.

G. The Administrator's review of medical and treatment charges pursuant

to this section shall be conducted pursuant to the Fee Schedule in existence

at the time the medical care or treatment was provided. The order approving

the medical and treatment charges pursuant to this section shall be

enforceable by the Court in the same manner as provided in the Workers'

Compensation Code for the enforcement of other compensation payments. Any

party feeling aggrieved by the order, decision or award of the Administrator

shall, within ten (10) days, have the right to request a hearing on such

medical and treatment charges by a judge of the Court. The judge of the

Court may affirm the decision of the Administrator, or reverse or modify the

decision only if it is found to be contrary to the Fee Schedule existing at

the time the medical care or treatment was provided. The order of the judge

Oklahoma Statutes - Title 85. Workers' Compensation

shall be subject to the same appellate procedure set forth for all other

orders of the Court.

H. Charges for prescription drugs dispensed by a pharmacy shall be

limited to ninety percent (90%) of the average wholesale price of the

prescription, plus a dispensing fee of Five Dollars ($5.00) per prescription.

"Average wholesale price" means the amount determined from the latest

publication designated by the Administrator. Physicians shall prescribe and

pharmacies shall dispense generic equivalent drugs when available. If the

National Drug Code (NDC) for the drug product dispensed is for a repackaged

drug, then the maximum reimbursement shall be the lesser of the original

labeler's NDC or the lowest cost therapeutic equivalent drug product.

Compounded medications shall be billed by the compounding pharmacy at the

ingredient level, with each ingredient identified using the applicable NDC of

the drug product, and the corresponding quantity. Ingredients with no NDC

area are not separately reimbursable. Payment shall be based upon a sum of

the allowable fee for each ingredient plus a dispensing fee of Five Dollars

($5.00) per prescription.

I. When medical care includes prescription drugs dispensed by a

physician or other medical care provider, the employer or insurance carrier

shall be required to pay the lesser of the reimbursement amount specified

under the schedule of fees adopted by the Administrator, the reimbursement

amount for prescription drugs obtained by mail order, when mail order is

available, or the reimbursement amount for prescription drugs obtained at a

retail pharmacy. If the NDC for the drug product dispensed is for a

repackaged drug, then the maximum reimbursement shall be the lesser of the

original labeler's NDC or the lowest cost therapeutic equivalent drug

product. Compounded medications shall be billed by the compounding pharmacy.

J. Implantables are paid in addition to procedural reimbursement paid

for medical or surgical services. A manufacturer's invoice for the actual

cost to a physician, hospital or other entity of an implantable device shall

be adjusted by the physician, hospital or other entity to reflect, at the

time implanted, all applicable discounts, rebates, considerations and product

replacement programs and must be provided to the payer by the physician or

hospital as a condition of payment for the implantable device. In the event

the physician, or an entity that the physician has a financial interest in,

other than an ownership interest of less than five percent (5%) in a publicly

traded company provides implantable devices, this relationship must be

disclosed to patient, employer, insurance company, third party administrator,

certified workplace medical plan, case managers, and attorneys representing

claimant and defendant. In the event the physician, or an entity that the

physician has a financial interest in, other than an ownership interest of

less than five percent (5%) in a publicly traded company, buys and resells

implantable devices to the hospital or another physician, that markup shall

be limited to ten percent (10%) above cost.

K. Payment for medical care as required by this act shall be due within

forty-five (45) days of the receipt by the employer or insurance carrier of a

complete and accurate invoice, unless the employer or insurance carrier has a

good faith reason to request additional information about such invoice.

Thereafter, a judge of the Court may assess a penalty up to twenty-five

percent (25%) for any amount due under the Fee Schedule that remains unpaid

upon the finding by the Court that no good faith reason existed for the delay

in payment. In the event the Court finds a pattern of an employer or

insurance carrier willfully and knowingly delaying payments for medical care,

the Court may assess a civil penalty of not more than Five Thousand Dollars

($5,000.00) per occurrence.

L. In the event an employee fails to appear for a scheduled appointment

with a physician, the employer or insurance company shall pay to the

Oklahoma Statutes - Title 85. Workers' Compensation

physician a reasonable charge, to be determined by the Administrator, for the

missed appointment. In the absence of a good faith reason for missing the

appointment, the Court shall order the employee to reimburse the employer or

insurance company for such charge.

M. Physicians providing treatment under this act shall disclose under

penalty of perjury to the Administrator of the Workers' Compensation Court,

on a form prescribed by the Administrator, any ownership or interest in any

health care facility, business, or diagnostic center that is not the

physician's primary place of business. Such disclosure shall include any

employee leasing arrangement between the physician and any health care

facility that is not the physician's primary place of business. A

physician's failure to disclose as required by this section shall be grounds

for the Administrator to disqualify the physician from providing treatment

under this act.