In our ever evolving world of medical treatment and fee schedule changes, it is imperative to stay current on the changes that apply to not only the type of services provided, but the rules that govern the value of the services.

The Official Medical Fee Schedule (OMFS) is used for payment of medical services required to treat work-related injuries and illnesses. The OMFS sets up specific formulas for various types of services provided to the injured worker and each of these formulas is updated to conform to the relevant Medicare and Medi-Cal changes pursuant to Labor Code 5307.1 (g) and Title 8, California Code of Regulations, section 9789.110. These updates are maintained on the DWC website.

Some of the recent changes include the Physician and Non-Physician Practitioner Fee Schedule based on the Medicare Federal Resource Based Relative Value Scale (RBRVS) which became effective for services on or after January 1, 2014. The 2015 transition conversion factors reflect a blend of 50 % pre-2014 OMFS Conversion Factor (CF) and 50% 120% RBRVS Medicare Conversion Factor (CF) .  This update became effective for services on or after March 1, 2015.

The update to the Inpatient Hospital Fee Schedule becomes effective based on the date of discharge for an inpatient stay on or after March 5, 2015. The amended regulation reiterates the applicable dates of fee schedule provisions that are declaratory of existing laws; addresses the operating disproportionate share hospital (DSH) adjustments to inpatient hospitals; addresses the inpatient hospital outlier payments for eligible transfer cases; updates inpatient hospital factors to 2014; and makes minor adjustments to various sections of the OMFS. Amended Section 9789.23 reflects the changes to the Composite Rate, Hospital Specific Outlier Factor and Cost to Charge Ratio for the listed California inpatients hospitals. Amended Section 9789.24 reflects Medicare’s changes to the Relative Weights and Geometric Mean Length of Stay for the listed Medicare Severity diagnosis-related groups.

The Outpatient Hospital Fee Schedule and Ambulatory Surgical Centers Fee Schedule are adjusted to conform to the hospital outpatient prospective payment system (HOPPS) changes which became effective on December 1, 2014. Now, for services rendered on or after September 1, 2014, only hospitals may charge or collect a facility fee for Emergency Room Visits, Facility Only Services, and Other Services.Only hospital outpatient departments and ambulatory surgical centers as defined in Section 9789.30(o) and Section 9789.30(c) may charge or collect a facility fee for surgical services provided on an outpatient basis. “Other Services” rendered on or after September 1, 2014 to hospital outpatients, the maximum allowable hospital outpatient facility fees shall be paid according to the OMFS RBRVS. (Note: Other provisions apply.)

There are also provisions for the other fee schedules for Ambulance Fees, Durable medical equipment, Pathology & Clinical Labs, Pharmaceuticals etc.

There may be exemptions to each of these fee schedules, and medical providers need to know when those exemptions apply to enable optimal recovery available under the law.