Physician Fee Schedule

Pursuant to KRS 342.035(1), the Commissioner of the Department of Workers' Claims is required to promulgate administrative regulations to adopt a schedule of fees for the purpose of ensuring that all fees, charges, and reimbursements under KRS 342.020 shall be fair, current, and reasonable. The medical fee schedule for physicians is reviewed and updated every two years on July 1. The current version became effective July 1, 2022. The 2022 medical fee schedule was established using medical billing data provided by FAIR Health, Inc., an independent, non-profit organization that collects data for and manages the nation's largest database of privately billed health insurance claims. The fee schedule may be purchased by ordering a copy from the Department online or conventionally through the following links:

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Hospital Fee Schedule

The Hospital Fee Schedule (cost-to-charge ratio) governs the reimbursement for hospital charges in workers’ compensation claims and these ratios are modified April 1st of each year. The calculations are determined by utilizing applicable figures taken from each facility’s cost report (HCFA-2552) on file with the Cabinet for Health and Family Services (CHFS).

Current Hospital Cost-to-Charge Ratios

The Cost-to-Charge ratio for Out-of-State Hospitals changes frequently- please check back often to ensure that you have the most up to date information possible.

Contacts

Managed Care

Of all the medical cost-containment measures enacted in the amendment of KRS 342.020 in 1994, managed care is of the most historical significance. For the first time employers were granted input into the matter of physician selection through managed care plans approved by the commissioner.

Employees still have choice of physician but within the confines of the provider network. (803 KAR 25:110) The Administrative Regulation establishing the standards for managed care plans was adopted on July 15, 1994. The first plan was approved in October and by November 1994, Kentucky workers were being treated under approved plans.

Managed care emphasizes controlling utilization through gatekeeper physicians, pre-certification of services, strong case management and coordination of medical treatment and return-to-work policies. Internal grievance procedures are required.

Managed care affords insuring interests a strong voice in selecting network providers.

Any managed care system may file a managed care plan for approval with the commissioner of the Department of Workers' Claims. Systems may operate more than one managed care plan. Employers and insurers may contract with multiple systems in order to maximize employee access. There is no application form nor application fee. Applications for certification must contain all the components of the regulation.

Plans are reviewed for compliance with the regulation. Some of the key requirements are:

• Identify the system and its components. Identify the key personnel including plan administrator, medical director (must have a Kentucky medical license) and case manager (must hold Kentucky certification).
• Demonstrate financial ability and professional expertise to perform all necessary functions. If applicants have previously provided managed care or similar services in the commonwealth, they must provide a summary of the administrative and medical services provided and a list of representative entities. If the applicant does not provide managed care in Kentucky, a performance bond or cash surety deposit of $500,000 will be required. A copy of the most recent audited financial statement is also required.
• The plan must demonstrate it will provide prompt and effective access to qualified medical services. The employees must have adequate choice and convenient geographic access to gatekeepers, specialists and facilities.
• Maintain a professional malpractice policy with limits of no less than $500,000 for an occurrence of professional negligence.

Conditions pre-requisite to out-of-plan provider access are:

• Emergency. Emergency means those medical services required for the immediate diagnosis or treatment of a medical condition that if not immediately diagnosed or treated could lead to serious physical or mental disability or death, or medical services that are immediately necessary to alleviate severe pain. "Emergency care" does not include follow-up care, except when immediate care is required to avoid serious disability or death. Employees who receive emergency care may elect to remain under the care of that physician as long as he or she complies with the utilization review and reporting requirements of the plan. Reimbursement of the non-plan providers will be at the level prescribed by applicable workers' compensation fee schedules.
• When referred by gatekeeper.
• When authorized treatment is unavailable within the plan.
• For a second opinion when surgery is recommended.
• When treatment is received for a work-related injury or disease prior to the plan being implemented with that employer, an employee may continue with that physician until treatment ends or until he or she changes physicians. Then the employee must choose a physician within the plan.

The plan must have the following:

• A grievance procedure.
• Utilization review and medical bill audit.
• Contracted medical fees.

The Plan must provide specimens of information materials and a toll-free phone number available 24 hours a day to inform all parties about plan operations, after-office-hours care and 24-hour access to emergency care.

The Plan must provide aggressive case management to coordinate the delivery of health services and return-to-work policies to promote an appropriate, prompt return to work and facilitate communication among the employee, employer and health care providers.

The plan must also describe the circumstances under which injured employees shall be subject to case management and the services to be provided.

Statutes and Regulations

Contacts

Managed Care Reporting Requirements

803 KAR 25:110, Section 11 - Reporting
Each managed health care system having a certified managed care plan shall submit:

1. An annual report to the commissioner on or before April 15 containing the following information for the previous year:
   1. Number of employees treated by the managed care plan;
   2. Number of employers and employees covered by the managed care plan; and
   3. Number of grievances filed, and summary of action;
2. On or before April 15 and October 15 of each year, a copy of the provider directory of participating medical providers shall be provided to the commissioner.
   

Approved Managed Care Organizations

Workers’ Compensation Managed Care is intended to enable employers to better regulate costs while also providing high-quality medical care by utilizing gatekeeper and specialist physicians, permitting pre-certification of services, maintaining aggressive case management and ensuring coordination of medical treatment.

Approved Managed Care Organizations

Vocational Rehabilitation

The Vocational Rehabilitation Program is a partnership between the Kentucky Department of Workers' Claims, an injured worker and local educational institutions. The goal of this partnership is to ensure the injured worker has the skills necessary to return to gainful employment.

University Evaluations

The Department of Workers' Claims' medical schedulers are responsible for the coordination of scheduling university evaluations at the University of Kentucky, the University of Louisville and Commonwealth Respiratory Consultants, pursuant to KRS 342.315. Examinations are conducted in all hearing loss claims, occupational disease claims and in claims by order of an administrative law judge.

Timely scheduling of university evaluations by the universities and preparing and sending reports are elements that are critical to the success of the program.

Statutes and Regulations

Contacts

Utilization Review

As part of the 1994 workers' compensation reform, KRS 342.035 required the commissioner of the Department of Workers' Claims to promulgate administrative regulations governing medical provider utilization review activities conducted by an insurance carrier, group self-insurer or self-insured employer. 803 KAR 25:190, requiring every individual self-insured employer, group self-insurance fund and insurance carrier to implement a utilization review and medical bill audit program and submit a written plan describing the program to the commissioner for approval, became effective Sept. 19, 1995.

In response to issues raised by medical providers and medical payment obligors, the regulation was revisited during the last quarter of 1997. Amendments to the regulation were promulgated and became effective June 15, 1998.

Legislative changes dealing with private review agent certification necessitated the most recent regulatory amendment effective March 19, 2001.

Utilization Review and Medical Bill Audit Approved Vendor List​​​​​

Kentucky Department of Workers' Claims Utilization Review/Medical Bill Audit Application
Utilization Review Check List
Medical Bill Audit Check List
Medical Bill Audit Plan (Attachment A)

Statutes and Regulations

Contact

Medical Services FAQ

Physician Disclosure

If a provider of medical services or treatment makes a referral for medical services or treatment to a provider or entity in which the medical provider making the referral has an investment interest, the referring provider shall disclose that investment interest to the employee, the Commissioner of the Department of Workers’ Claims, and the employer’s insurer or the party responsible for payment for the services within thirty (30) days from the date the referral was made. Pursuant to KRS 342.020(9).