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Virginia Medical Fee Schedule – Hell May Freeze Over After All


Virginia Medical Fee Schedule Passed By House and Senate

A new Virginia medical fee schedule is in the works.   One of the last holdouts on not having a fee schedule is going to have one January 2018.   I was actually shocked that a Virginia medical fee schedule was not in place earlier.

concept of virginia medical fee schedule dollars medicines and stethoscope

The title of this article is based on an old adjuster friend of mine from Virginia.   He had said hell would freeze over before Virginia enacts a medical fee schedule.

Virginia is quite the business-friendly state.  The new fee schedule should lower costs if the proper one is put into place.   The Virginia Senate Bill text summary is included below.   Please note this has been edited to show some of the highlights.   The full text can be found here.

Workers’ compensation; fee schedules for medical services.

In absence of a contract under which the provider has agreed to accept a specified amount for the medical service.– Is this a PPO network or a fee for service denotation?

The regulations implementing the fee schedules shall become effective on January 1, 2018.

Picture of stethoscope and cash virginia medical fee schedule concept
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The Commission is required to retain a firm to assist it in establishing the initial fee schedules.

Could they not have just extrapolated fee schedules from neighboring states such as North Carolina and West Virginia?

Reimbursements for medical services provided to treat traumatic injuries and serious burns are excluded from the fee schedules and liability for their treatment costs will be based, absent a contract, on 80 percent of the provider’s charges. However, the required reimbursement will be 100 percent of the provider’s charges if the employer unsuccessfully contests the compensability of the claim.  

This is an interesting point.  I would think carriers and TPA’s would consider the penalty before denying a traumatic injury file in Virginia.

Providers are prohibited from using a different charge master or schedule of fees for any medical service provided for workers’ compensation patients than the provider uses for health care services provided to patients who are not claimants. 

Can the medical providers not charge less than health if that is the billing practice?

Medical Payment Virginia Medical Fee Schedule Big hand Carrying Man Feet

The measure prohibits certain practices involving the use by third parties of contracts whereby a provider agrees to accept payment of less than the fee-scheduled amount, including restricting the sale, lease, or other dissemination of information regarding the payment amounts or terms of a provider contract without the express written consent and prior notification of all parties to the provider contract and prohibiting an employer from shopping for the lowest discount for a specific provider among the provider contracts held in multiple PPO networks.

This would be the old no PPO stacking legislation already in place in many states.

The regulatory advisory panel is directed to make recommendations to the Commission prior to July 1, 2017, on workers’ compensation issues relating to (i) pharmaceutical costs not previously included in the fee schedules, (ii) durable medical equipment costs not previously included in the fee schedules, (iii) certain awards of attorney fees, (iv) peer review of medical costs, (v) prior authorization for medical services, and (vi) other issues that the Commission assigns to it. The existing peer review provisions are repealed.  

The Virginia medical fee schedule is going to cover pharmaceuticals and durable medical.   One has to wonder what level of control they will have over these two areas.

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
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  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
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