Newsline No. 35-09 printer image Printer friendly

July 1, 2009

 

Division of Workers' Compensation responds to inquiries regarding payment for medical treatment

The Division of Workers’ Compensation (DWC) has recently received inquiries regarding whether the Medicare payment rules apply when paying for medical costs under the California official medical fee schedule (OMFS). 

Labor Code section 4600 provides that reasonably required medical treatment to cure or relieve the effects of the injury, means treatment based upon the medical treatment utilization schedule (MTUS) guidelines adopted by the administrative director. 

The MTUS, not Medicare coverage rules, apply to determine what treatment is reasonably required.  If a question arises regarding whether a treatment is medically reasonable and necessary, the claims administrator should use the workers’ compensation utilization review procedures to determine the issue, as required by Labor Code section 4610 and title 8, California Code of Regulations section 9792.6 et seq. 

Medical providers and payers should examine the various fee schedules in the OMFS to determine which Medicare fee-related payment rules have been adopted.  For example, DWC has adopted the Medicare ambulance fee schedule fact sheet for CY 2009.

The official medical fee schedule and administrative director’s update orders can be found on the DWC Web site at http://www.dir.ca.gov/dwc/OMFS9904.htm.

Claims administrators are also reminded to pay all undisputed amounts in a timely manner as required by Labor Code section 4603.2.

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