§ 28-33-7 — § 28-33-7. Health service provider reimbursement.

§ 28-33-7. Health service provider reimbursement.

(a) Any dispute as to the reasonableness of the amount of any charge and/or payment for medical, dental, or hospital services or for medicines or appliances shall be determined by the workers' compensation court after a hearing, and the decision shall be final; provided, that the director of the department of labor and training, in consultation with the workers' compensation court, and representatives of all appropriate medical disciplines practicing within the state of Rhode Island, shall establish a schedule of rates of reimbursement for those medical and dental services, excluding non-physician hospital charges, that are most often provided to employees receiving workers' compensation. The schedule shall be published by the director utilizing the Physician's Current Procedure Terminology (CPT) coding system as published by the American Medical Association. The director shall update and revise the schedule as necessary. In setting the rate of reimbursement for any service or procedure, the director shall determine, based upon available data, the ninetieth (90th) percentile of the usual and customary fee charged by healthcare providers in the state of Rhode Island and the immediate surrounding area, and in no case shall the rate of reimbursement exceed that amount. The liability of the employer or insurer for any charges and/or payment shall be limited to the rates of reimbursement set forth in this schedule including, but not limited to, charges for opinions on loss of use and maximum medical improvement; provided, that petitions may be filed in cases where the reasonableness of a particular rate is questioned, but the court shall be limited to a determination as to whether the rate, as applied in that particular case, is reasonable. The burden shall be upon the petitioner seeking payment of the medical bill to establish by a preponderance of the evidence that the rate, as applied, is unreasonable in light of the peculiar nature of the services performed or other circumstances requiring a greater than normal expertise or expenditure of time or effort in providing the service.

(b) Subject to the provisions of subsection (a) of this section, disputes other than those covered in § 28-33-9 pertaining to hospitalizations, medical services, appliances, or medicine shall be heard and determined by the workers' compensation court in accordance with guidelines and protocols established by the medical advisory board.

(c) With respect to all complaints and charges of unprofessional conduct including, but not limited to, unnecessary or inappropriate treatment and any overcharges against any medical care provider brought to the attention of the workers' compensation court in the performance of their duties under this title, the court shall report all complaints and charges to the appropriate board of licensure and discipline.

(d) The chief judge is authorized to establish a healthcare fee arbitration panel and to establish rules and procedure for the panel to make binding decisions in any dispute as to the value of healthcare services rendered under this title, and to compensate its members in an amount not to exceed two hundred dollars ($200) per day. The panel shall consist of one physician appointed by the president of the Rhode Island Medical Society, one physician who is a member of the Rhode Island Medical Society appointed by the manager of the state workers' compensation insurance fund, and one physician who is a member of the Rhode Island Medical Society appointed by the chief judge of the workers' compensation court.

Legislative History

P.L. 1912, ch. 831, art. 2, § 5; P.L. 1917, ch. 1534, § 2; P.L. 1921, ch. 2095, § 4; G.L. 1923, ch. 92, art. 2, § 5; P.L. 1926, ch. 764, § 4; P.L. 1936, ch. 2290, § 4; P.L. 1936, ch. 2358, § 4; P.L. 1937, ch. 2545, § 1; G.L. 1938, ch. 300, art. 2, § 5; P.L. 1941, ch. 1051, § 1; P.L. 1942, ch. 1226, § 1; P.L. 1947, ch. 1832, § 1; P.L. 1954, ch. 3297, § 1; P.L. 1955, ch. 3540, § 1; G.L. 1956, § 28-33-7; P.L. 1978, ch. 194, § 1; P.L. 1979, ch. 391, § 1; P.L. 1982, ch. 32, art. 1, § 6; P.L. 1985, ch. 365, § 6; P.L. 1986, ch. 507, § 7; P.L. 1990, ch. 279, § 4; P.L. 1990, ch. 332, art. 1, § 3; P.L. 1990, ch. 332, art. 3, § 4; P.L. 1992, ch. 31, § 5; P.L. 2003, ch. 388, § 3; P.L. 2003, ch. 395, § 3.