This text of Indiana § 22-3-3-5.2 (Billing review service standards) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
2.
(a)A billing review service shall adhere to
the following requirements to determine the pecuniary liability of an
employer or an employer's insurance carrier for a specific service or
product covered under worker's compensation provided before July 1,
2014, by all medical service providers, and after June 30, 2014, by a
medical service provider that is not a medical service facility:
(1)The formation of a billing review standard, and any
subsequent analysis or revision of the standard, must use data that
is based on the medical service provider billing charges as
submitted to the employer and the employer's insurance carrier
from the same community. This subdivision does not apply when
a unique or specialized service or product does not have sufficient
comparative data to allow for a
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2. (a) A billing review service shall adhere to
the following requirements to determine the pecuniary liability of an
employer or an employer's insurance carrier for a specific service or
product covered under worker's compensation provided before July 1,
2014, by all medical service providers, and after June 30, 2014, by a
medical service provider that is not a medical service facility:
(1) The formation of a billing review standard, and any
subsequent analysis or revision of the standard, must use data that
is based on the medical service provider billing charges as
submitted to the employer and the employer's insurance carrier
from the same community. This subdivision does not apply when
a unique or specialized service or product does not have sufficient
comparative data to allow for a reasonable comparison.
(2) Data used to determine pecuniary liability must be compiled
on or before June 30 and December 31 of each year.
(3) Billing review standards must be revised for prospective
future payments of medical service provider bills to provide for
payment of the charges at a rate not more than the charges made
by eighty percent (80%) of the medical service providers during
the prior six (6) months within the same community. The data
used to perform the analysis and revision of the billing review
standards may not be more than two (2) years old and must be
periodically updated by a representative inflationary or
deflationary factor. Reimbursement for these charges may not
exceed the actual charge invoiced by the medical service
provider.
(b) This subsection applies after June 30, 2014, to a medical service
facility. The pecuniary liability of an employer or an employer's
insurance carrier for a specific service or product covered under
worker's compensation and provided by a medical service facility is
equal to a reasonable amount, which is established by payment of one
(1) of the following:
(1) The amount negotiated at any time between the medical
service facility and any of the following:
(A) The employer.
(B) The employer's insurance carrier.
(C) A billing review service on behalf of a person described in
clause (A) or (B).
(D) A direct provider network that has contracted with a person
described in clause (A) or (B).
(2) Two hundred percent (200%) of the amount that would be
paid to the medical service facility on the same date for the same
service or product under the medical service facility's Medicare
reimbursement rate, if, after conducting the negotiations
described in subdivision (1), an agreement has not been reached.
(c) A medical service provider may request an explanation from a
billing review service if the medical service provider's bill has been
reduced as a result of application of the eightieth percentile or of a
Current Procedural Terminology (CPT) or Medicare coding change.
The request must be made not later than sixty (60) days after receipt of
the notice of the reduction. If a request is made, the billing review
service must provide:
(1) the name of the billing review service used to make the
reduction;
(2) the dollar amount of the reduction;
(3) the dollar amount of the service or product at the eightieth
percentile; and
(4) in the case of a CPT or Medicare coding change, the basis
upon which the change was made;
not later than thirty (30) days after the date of the request.
(d) If, after a hearing, the worker's compensation board finds that a
billing review service used a billing review standard that did not
comply with subsection (a)(1) through (a)(3), as applicable, in
determining the pecuniary liability of an employer or an employer's
insurance carrier for a medical service provider's charge for services or
products covered under worker's compensation, the worker's
compensation board may assess a civil penalty against the billing
review service in an amount not less than one hundred dollars ($100)
and not more than one thousand dollars ($1,000).