Medical Fees

Massachusetts Workplace Disability Lawyers

The Massachusetts workers’ compensation attorneys at Kantrovitz & Associates are committed to helping injured workers recover compensation for medical fees incurred as a result of a job-related injury. For over 25 years, our law firm has focused on obtaining the best possible treatment at fair rates for temporary and permanent disabilities. We recover benefits from employers and insurers on behalf of workers throughout Massachusetts, Rhode Island, and New Hampshire.

Medical Treatment Rates

Massachusetts General Law (MGL) c. 152 § 13 authorizes the Division of Health Care Finance and Policy (Division) to establish rates of payment for hospitals and health care providers. But § 118G also allows employers, workers’ compensation insurers, and doctors to set different payment rates for providing medical treatment. Hospitals and medical service providers are therefore not bound by the administrative bulletin (AB) published by the Division.

AB 13-11, for example, sets forth the most current payment rates for services provided to industrial accident patients under the Workers’ Compensation Act. However, medical providers can negotiate higher fees, which insurers are willing to pay. Pursuant to the published AB, the updated “uniform assessment” for hospital outpatient workers’ compensation charges involves:

• Revision from .8% to .83% for health care services
• Addition of percentage change to acute hospital charges
• Application when payment for patient is based on ambulatory fees
• Additional percentage includes restorative services and surgical fees

The Division does not determine medical necessity or clinical support for medical procedures. Instead, third party vendors, through the Department of Industrial Accidents, perform utilization review. The most current payment rates for health care services are governed by 114.3 Code of Massachusetts Regulations (CMR) 40.00, which lists fee schedules used to pay doctors and physical therapists.

Scope of Coverage

The published AB rates constitute full payment for treatment provided to injured workers, including related administrative or overhead costs. Although the providers may agree on a different fee for services, no employee is liable for payment of covered health care services under workers’ compensation. Compensable medical expenses may include:

• Surgical supplies
• Prosthetic devices
• Personal daily care
• Respiratory therapy
• Implants, accessories
• Customized equipment
• Consultation, diagnosis
• Electric nerve stimulator
• Rehabilitation technology

Medical providers must report an unlisted procedure or service in a “special report” when billing the insurer. In no case can an employee be billed for balances in excess of the rates set by the Division. Providers must file a third-party lien against the insurer for the difference. Pharmacy payments for prescription drugs are governed by a different regulation, 114.3 CMR 31.00.

Recovering Medical Fees

If you have questions about obtaining necessary medical services or reimbursement of health care fees, contact the Massachusetts workers’ compensation lawyers at Kantrovitz & Associates today. For over 25 years, our caring attorneys have guided patients through the complex state regulatory structure to determine fees for unlisted medical services and equipment. At Kantrovitz & Associates, we understand that injured workers should receive necessary treatment, not worry about medical expenses while out of work. That is why we remain up to date on evolving AB schedules and help you obtain the services you need. We recover workers’ compensation benefits for clients throughout Boston, Essex, Middlesex, Norfolk, Suffolk, Plymouth, and Merrimack Counties, among others. Call 800-367-0871 for a free consultation or contact us online.