Any medical providers with billing claims pending before the Virginia Worker’s Compensation Commission will want to follow closely the potential actions by Congress in dealing with CMS payment rates. That is because many workers’ compensation repricing network contracts allow the networks to base their worker’s comp reimbursements upon CMS rates for each procedure code.

Right now, Congress is considering reducing reimbursements to providers due to federal budget constraints. For many providers, participation in Medicare is a matter of professional duty, with care being provided partly as a public service, given the knowledge that payments will be woefully below true value. If reimbursement rates are cut still more, the cost of participation may rise so high that more and more providers opt out of the federal systems by declining [Medicare or Medicaid?] patients.

Each provider will need to make its own decision as to whether or not to continue participating in any system that requires the provider to work below cost. That approach has always applied to worker’s comp as well, but due to the often direct relationship between CMS rates and worker’s comp reimbursements, providers need to be alert to the possible need to make a business decision this year.

That decision need not be to stop treating worker’s comp patients.  Rather, it would merely require the provider to exit all workers’ comp networks, treating comp patients only on an “out of network” basis.  In those situations, Virginia law mandates payment according to “prevailing community rates” or PCR – rates that are determined according to statistical evidence reviewed on a case-by-case basis, without regard for CMS payment schedules.
Any medical provider needing help with its worker’s compensation network relationships, or just with getting fairly paid on worker’s compensation billings, should contact MG Law.

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