Latest Edition Includes Regulations for Telehealth, Ambulance Fees, Balance Billing, and Fees for Surgical Implants

Cambridge, MA, March 30, 2021―With medical benefits representing the single largest cost component for many state workers’ compensation systems, the Workers Compensation Research Institute (WCRI) released a new study today that provides a basic understanding of the cost containment strategies used in all 50 states and 3 federal workers’ compensation programs as of January 1, 2021.

The study, Workers’ Compensation Medical Cost Containment: A National Inventory, 2021, includes tables of statutory provisions, administrative rules, and processes used by states as of January 1, 2021. The information contained in the tables comes from surveys completed by state and federal administrators. One of the most popular tables (Table 4) compares fee schedule allowances for eight of the most common medical procedures (e.g., knee arthroscopy, lumbar surgery) in states that regulate fees.

New to this report are four medical cost issues that have received a great deal of attention since the last edition:

• Telehealth: In spring 2020, when many medical practices were physically closed and offering only remote care, some state agencies expanded the use of telehealth for workers with injuries. Table 23 describes how telehealth visits are allowed, restricted, and paid under workers’ compensation rules. It also indicates whether the rules were changed due to COVID-19 and whether they have sunset provisions.
• Ambulance Transportation: The workers’ compensation community has been increasingly concerned about growing costs of ambulance transportation, especially for air ambulances. Table 24 shows whether there is any fee regulation, utilization review, or other cost containment mandated for ground and air ambulance services. It also describes how to calculate a maximum allowed fee for jurisdictions that set a maximum. 
• Balance Billing: This is the practice of billing a medical patient for the difference between what the provider charged and what the payor paid. It may also describe billing a patient the full cost of services after the payor has denied them. Tables 20 and 24 include columns that show whether balance billing is forbidden in the jurisdiction.
• Surgical Implants: The cost of surgically implanted hardware is often reimbursed separately from the procedure itself, and not all jurisdictions regulate that payment the same way. Table 5 includes two new columns showing whether hardware reimbursements are regulated, and if so, the method for calculating the appropriate fee.

“Cost containment strategies have to balance ensuring access to quality medical care for workers against limiting the cost of services and avoiding inappropriate treatment,” said Ramona Tanabe, WCRI’s executive vice president and counsel. “Though they go about it differently, all the state and federal programs are trying to do the same thing. This report pulls all that information together to allow policymakers and other stakeholders to make more sense of what they might be seeing in their own state and across the country.”

For more information on this study or to purchase a copy, visit https://www.wcrinet.org/reports/workers-compensation-medical-cost-containment-a-national-inventory-2021. Karen Rothkin is the author of the study.

About WCRI:

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Cambridge, MA. Organized in late 1983, the Institute does not take positions on the issues it researches; rather, it provides information obtained through studies and data collection efforts, which conform to recognized scientific methods. Objectivity is further ensured through rigorous, unbiased peer review procedures. WCRI's diverse membership includes employers; insurers; governmental entities; managed care companies; health care providers; insurance regulators; state labor organizations; and state administrative agencies in the U.S., Canada, Australia, and New Zealand.

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