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You are here: Home . wc . news . advisories . ad93-08

Advisory 93-08

Fee Guidelines Reimbursement

There is a difference between the reimbursement for services covered by the Medical Fee Guideline and services covered by the Hospital Fee Guideline.

Commission Rule 134.201(a) states that "The maximum allowable payment for medical services rendered to injured employees in accordance with the Texas Workers' Compensation Act is the Medical Fee Guideline, which is the lesser of:

(1) the providers' usual fees and charges; or the fees and charges established" ... in the Medical Fee Guideline.

The Medical Fee Guideline is effective for all medical services on and after December 11, 1191, regardless of the date of injury.

Commission Rule 134.400 states that the Acute Care Inpatient Hospital Fee Guideline ... "establishes a per diem based payment system for services rendered to injured employees covered by workers' compensation insurance." Insurance carriers shall pay the per diem amount for services covered by the Guideline without regard to the amount of the hospital bill. In some cases this will result in paying less than the billed amount, in other cases, it will result in paying more than the billed amount.

The Acute Care Inpatient Hospital Fee Guideline is effective for all acute inpatient medical services rendered on and after September 1, 1992 to employees injured on or after January 1, 1991.

(There is no date signed noted)

Todd K. Brown
Executive Director

Distribution:

TWCC Staff
Carrier Representatives
Medical Advisory Committee
Medical Review Staff
Public Information List



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