Section 23.30.097. Fees for medical treatment and services.

   (a) All fees and other charges for medical treatment or service are subject to regulation by the board consistent with this section. A fee or other charge for medical treatment or service
        (1) rendered in the state may not exceed the lowest of 
             (A) the usual, customary, and reasonable fees for the treatment or service in the community in which it is rendered, for treatment or service provided on or after December 31, 2010, not to exceed the fees or other charges as specified in the fee schedules established by the medical services review committee and adopted by the board in regulation; the fee schedules must include
                  (i)  a physician fee schedule based on the federal Centers for Medicare and Medicaid Services' resource-based relative value scale;
                  (ii) an outpatient and ambulatory surgical center fee schedule based on the federal Centers for Medicare and Medicaid Services' ambulatory payment classification; and
                  (iii) an inpatient hospital fee schedule based on the federal Centers for Medicare and Medicaid Services' Medicare severity diagnosis related group;
             (B) the fee or charge for the treatment or service when provided to the general public; or
             (C) the fee or charge for the treatment or service negotiated by the provider and the employer under (c) of this section;
        (2) rendered in another state may not exceed the fee or charge for a treatment or service set by the workers' compensation statutes of the state where the services are rendered.
   (b) An employer or group of employers may establish a list of preferred physicians and treatment service providers to provide medical, surgical, and other attendance or treatment services to the employer's employees under this chapter; however,
        (1) the employee's right to chose the employee's attending physician under AS 23.30.095(a) is not impaired;
        (2) when given to the employee, the employer's preferred physician list must clearly state that the list is voluntary, that the employee's choice is not restricted to the list, that the employee's rights under this chapter are not impaired by choosing an attending physician from the list, and that, if the employee chooses an attending physician from the list, the employee may, in the manner provided in AS 23.30.095, make one change of attending physician, from the list or otherwise; and
        (3) establishment of a list of preferred physicians does not affect the employer's choice of physician for an employer medical examination under AS 23.30.095.
   (c) An employer or group of employers may negotiate with physicians and other treatment service providers under this chapter to obtain reduced fees and service charges and may take the fees and charges into account when forming a list of preferred physicians and providers. In no event may an employer or group of employers attempt to influence the treatment, medical decisions, or ratings by the physicians in the course of the negotiations of such a preferred physician and provider fee plans.
   (d) An employer shall pay an employee's bills for medical treatment under this chapter, excluding prescription charges or transportation for medical treatment, within 30 days after the date that the employer receives the provider's bill or a completed report as required by AS 23.30.095(c), whichever is later.
   (e) A physician or other provider of treatment services under this chapter, including hospital services, that submits a bill for medical treatment to the insurer or self-insured employer shall also submit a copy of the bill to the employee to whom the treatment was provided. An employee who notifies the insurer or self-insured employer's adjuster in writing of an overcharge in the bill that was not previously identified by the insurer or self-insured employer's adjuster shall be entitled to a reward equal to 25 percent of the billing reduction or reimbursement achieved due to the employee's report. This reward does not apply to overcharges of an amount under $100 if the insurer or self-insured employer's adjuster elects not to pursue correction of the bill.
   (f) An employee may not be required to pay a fee or charge for medical treatment or service provided under this chapter.
   (g) Unless the employer controverts a charge, the employer shall reimburse an employee's prescription charges under this chapter within 30 days after the employer receives the health care provider's completed report and an itemization of the prescription charges for the employee. Unless the employer controverts a charge, an employer shall reimburse any transportation expenses for medical treatment under this chapter within 30 days after the employer receives the health care provider's completed report and an itemization of the dates, destination, and transportation expenses for each date of travel for medical treatment. If the employer does not plan to make or does not make payment or reimbursement in full as required by this subsection, the employer shall notify the employee and the employee's health care provider in writing that payment will not be made timely and the reason for the nonpayment. The notification must be provided not later than the date that the payment is due under this subsection.
   (h) A provider of medical treatment or services may receive payment for medical treatment and services under this chapter only if the bill for services is received by the employer within 180 days after the later of
        (1) the date of service; or
        (2) the date that the provider knew of the claim and knew that the claim related to employment.
   (i) A provider whose bill has been denied or reduced by the employer may file an appeal with the board within 60 days after receiving notice of the denial or reduction. A provider who fails to file an appeal of a denial or reduction of a bill within the 60-day period waives the right to contest the denial or reduction.
   (j) The board shall annually renew and adjust fees on the fee schedules established by the medical services review committee under (a)(1)(A) of this section by a conversion factor established by the medical services review committee and adopted by the board in regulation.
   (k) A fee or other charge for medical treatment or service rendered in another state may not exceed the lowest of
        (1) the fee or charge for a treatment or service set by the workers' compensation statutes of the state where the service is rendered; or
        (2) the fees specified in a fee schedule under (a)(1)(A) of this section.
   (l) A fee or other charge for air ambulance services rendered under this chapter shall be reimbursed at a rate established by the board and adopted in regulation.
   (m) A fee or other charge for durable medical equipment not otherwise included in a covered medical procedure under this section may not exceed the amount of the manufacturer's invoice, plus a markup specified by the board and adopted in regulation.
   (n) Reimbursement for prescription drugs under this chapter may not exceed the amount of the original manufacturer's invoice, plus a dispensing fee and markup specified by the board and adopted in regulation.
   (o) A prescription drug dispensed by a physician under this chapter shall include in a bill or invoice the original manufacturer's code for the drug from the national drug code directory published by the United States Food and Drug Administration.
   (p) A fee or other charge for medical treatment or service provided by a hospital licensed by the Department of Health and Social Services to operate as a critical access hospital is exempt from the fee schedules established under (a)(1)(A) of this section.
   (q) The board may adjust the fee schedules established under (a)(1)(A) of this section to reflect the cost in the geographical area where the services are provided.
   (r) The medical services review committee shall formulate a conversion factor and submit the conversion factor to the commissioner of labor and workforce development. If the commissioner does not approve the conversion factor, the medical services review committee shall revise the conversion factor and submit the revised conversion factor to the commissioner for approval.

Notes

Implemented As

8 AAC 45.082
8 AAC 45.083
8 AAC 45.900

References

8 AAC 45.525

History

(Sec. 36 ch 10 FSSLA 2005; am Sec. 1 ch 39 SLA 2007; am Sec. 1 ch 4 SLA 2009; am Sec. 1 ch 32 SLA 2011; am Sec. 1, 2 ch 55 SLA 2014; am Sec. 2 ch 63 SLA 2014)