Medical service fee schedules
- • basis of fees
- • application to service provided by managed care organization
- • resolution of fee disputes
- • rules
(1) The Director of the Department of Consumer and Business Services, in compliance with ORS 656.794 (Advisory committee on medical care) and ORS chapter 183, shall promulgate rules for developing and publishing fee schedules for medical services provided under this chapter. These schedules shall represent the reimbursement generally received for the services provided. Where applicable, and to the extent the director determines practicable, these fee schedules shall be based upon any one or all of the following:
(a) The current procedural codes and relative value units of the Department of Health and Human Services Medicare Fee Schedules for all medical service provider services included therein;
(b) The average rates of fee schedules of the Oregon health insurance industry;
(c) A reasonable rate of markup for the sale of medical devices or other medical services;
(d) A commonly used and accepted medical service fee schedule; or
(e) The actual cost of providing medical services.
(2) Medical fees equal to or less than the fee schedules published under this section shall be paid when the vendor submits a billing for medical services. In no event shall that portion of a medical fee be paid that exceeds the schedules.
(3) In no event shall a provider charge more than the provider charges to the general public.
(4) If no fee has been established for a given service or procedure the director may, in compliance with ORS 656.794 (Advisory committee on medical care) and ORS chapter 183, promulgate a reasonable rate, which shall be the same within any given area for all primary health care providers to be paid for that service or procedure.
(5) At the request of the director and in the method and manner prescribed by rule, all providers of health insurance, as defined by ORS 731.162 (“Health insurance”), shall cooperate and consult with the director in providing information reasonably necessary and available to develop the fee schedules prescribed under subsection (1) of this section. A provider shall not be required to provide information or data that the provider deems proprietary or confidential. However, the information provided shall be considered proprietary and shall not be released by the director. The director shall not require such information from a health insurance provider more than once per year and shall reimburse the provider’s costs for providing the required information.
(6) Notwithstanding subsection (1) or (2) of this section, such rates or fees provided in subsections (1) and (2) of this section shall be adequate to insure at all times to the injured workers the standard of services and care intended by this chapter.
(7) The director shall update the schedule required by subsection (1) of this section annually. As appropriate and applicable, the update shall be based upon:
(a) A statistically valid survey by the director of medical service fees or markups;
(b) That information provided to the director by any person or state agency having access to medical service fee information;
(c) That information provided to the director pursuant to subsection (5) of this section; or
(d) The annual percentage increase or decrease in the physician’s services component of the national Consumer Price Index published by the Bureau of Labor Statistics of the United States Department of Labor.
(8) The director is prohibited from adopting or administering rules which treat manipulation, when performed by an osteopathic physician, as anything other than a separate therapeutic procedure which is paid in addition to other services or office visits.
(9) The director may, by rule, establish a fee schedule for reimbursement for specific hospital services based upon the actual cost of providing the services.
(10) A medical service provider is not authorized to charge a fee for preparing or submitting a medical report form required by the director under this chapter.
(11) Notwithstanding any other provision of this section, fee schedules for medical services and hospital services shall apply to those services performed by a managed care organization certified pursuant to ORS 656.260 (Certification procedure for managed health care provider), unless otherwise provided in the managed care contract.
(12) When a dispute exists between an injured worker, insurer or self-insured employer and a medical service provider regarding either the amount of the fee or nonpayment of bills for compensable medical services, notwithstanding any other provision of this chapter, the injured worker, insurer, self-insured employer or medical service provider may request administrative review by the director. The decision of the director is subject to review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim).
(13) The director may exclude hospitals defined in ORS 442.470 (Definitions for ORS 442.470 to 442.507) from imposition of a fee schedule authorized by this section upon a determination of economic necessity. [Amended by 1965 c.285 §26; 1969 c.611 §1; 1971 c.329 §1; 1981 c.535 §5; 1983 c.816 §6; 1985 c.107 §1; 1985 c.739 §5; 1987 c.884 §42; 1990 c.2 §14; 1995 c.332 §26; 1999 c.233 §1; 2005 c.26 §6; 2009 c.36 §2]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.