342.035 Administrative regulations -- Medical fee schedule -- Review and updating
936 words·~4 min read·
/ky/342-035A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
-- Action for excess fees -- Effect of failure to submit to or follow surgical or
medical treatment or advice -- Certification to commissioner -- Audit --
Utilization review -- Report -- Copies of records -- Practice parameters and
evidence-based guidelines -- Formulary -- Medical fee schedule for registered
nurse first assistants.
(1)Periodically, the commissioner shall promulgate administrative regulations to adopt
a schedule of fees for the purpose of ensuring that all fees, charges, and
reimbursements under KRS 342.020 and this section shall be fair, current, and
reasonable and shall be limited to such charges as are fair, current, and reasonable
for similar treatment of injured persons in the same community for like services,
where treatment is paid for by general health insurers. In determining what fees are
reasonable, the commissioner may also consider the increased security of payment
afforded by this chapter. On or before November 1, 1994, and on July 1 every two
(2)years thereafter, the schedule of fees contained in administrative regulations
promulgated pursuant to this section shall be reviewed and updated, if appropriate.
Within ten
(10)days of April 4, 1994, the commissioner shall execute a contract
with an appropriately qualified consultant pursuant to which each of the following
elements within the workers' compensation system are evaluated; the methods of
health care delivery; quality assurance and utilization mechanisms; type, frequency,
and intensity of services; risk management programs; and the schedule of fees
contained in administrative regulation. The consultant shall present
recommendations based on its review to the commissioner not later than sixty
days following execution of the contract. The commissioner shall consider these
recommendations and, not later than thirty
(30)days after their receipt, promulgate
a regulation which shall be effective on an emergency basis, to effect a twenty-five
percent (25%) reduction in the total medical costs within the program.
(2)No provider of medical services or treatment required by this chapter, its agent,
servant, employee, assignee, employer, or independent contractor acting on behalf
of any medical provider, shall knowingly collect, attempt to collect, coerce, or
attempt to coerce, directly or indirectly, the payment of any charge, for services
covered by a workers' compensation insurance plan for the treatment of a work-
related injury or occupational disease, in excess of that provided by a schedule of
fees, or cause the credit of any employee to be impaired by reason of the employee's
failure or refusal to pay the excess charge. In addition to the penalty imposed in
KRS 342.990 for violations of this subsection, any individual who sustains damages
by any act in violation of the provisions of this subsection shall have a civil cause of
action in Circuit Court to enjoin further violations and to recover the actual
damages sustained by the individual, together with the costs of the lawsuit,
including a reasonable attorney's fee.
(3)Where these requirements are furnished by a public hospital or other institution,
payment thereof shall be made to the proper authorities conducting it. No
compensation shall be payable for the death or disability of an employee if his or
her death is caused, or if and insofar as his disability is aggravated, caused, or
continued, by an unreasonable failure to submit to or follow any competent surgical
treatment or medical aid or advice.
(4)The commissioner shall, by December 1, 1994, promulgate administrative
regulations to adopt a schedule of fees for the purpose of regulating charges by
medical providers and other health care professionals for testimony presented and
medical reports furnished in the litigation of a claim by an injured employee against
the employer. The workers' compensation medical fee schedule for physicians, 803
KAR 25:089, having an effective date of February 9, 1995, shall remain in effect
until July 1, 1996, or until the effective date of any amendments promulgated by the
commissioner, whichever occurs first, it being determined that this administrative
regulation is within the statutory grant of authority, meets legislative intent, and is
not in conflict with the provisions of this chapter. The medical fee schedule and
amendments shall be fair, current, and reasonable and otherwise comply with this
section.
(a)To ensure compliance with subsections
(1)and
(4)of this section, the
commissioner shall promulgate administrative regulations by December 31,
1994, which require each insurance carrier, self-insured group, and self-
insured employer to certify to the commissioner the program or plan it has
adopted to ensure compliance.
(b)In addition, the commissioner shall periodically have an independent audit
conducted by a qualified independent person, firm, company, or other entity
hired by the commissioner, in accordance with the personal service contract
provisions contained in KRS 45A.690 to 45A.725, to ensure that the
requirements of subsection
(1)of this section are being met. The independent
person, firm, company, or other entity selected by the commissioner to
conduct the audit shall protect the confidentiality of any information it
receives during the audit, shall divulge information received during the audit
only to the commissioner, and shall use the information for no other purpose
than the audit required by this paragraph.
(c)The commissioner shall promulgate administrative regulations governing
medical provider utilization review activities conducted by an insurance
carrier, self-insured group, or self-insured employer pursuant to this chapter.
Utilization review required under administrative regulations may be waived if
the insurance carrier, self-insured group, or self-insured employer agrees that
the recommended medical treatment is medically necessary and appropriate or
if the injured employee elects not to proceed with the recommended medical
treatment.
(d)Periodically, or upon request, the commissioner shall report to the Interim
Joint Committee on Economic Development and Workforce Investment of the