19 Del. Admin. Code § 1341-1.0

Current through Reigster Vol. 28, No. 6, December 1, 2024

Section 1341-1.0 - Purpose and Scope

1.1 Section 2322B, Chapter 23, Title 19, Delaware Code authorizes and directs the Department of Labor to adopt a Health Care Payment System by regulation after promulgation by the Workers' Compensation Oversight Panel.

1.2 Section 2322B, Chapter 23, Title 19, Delaware Code, authorizes and directs the Workers' Compensation Oversight Panel to adopt and recommend a coordinated set of instructions and guidelines to accompany the health care payment system, to the Department for adoption by regulation.

1.3 Section 2322B(3), Chapter 23, Title 19, Delaware Code establishes the fee schedule framework for hospitals, ambulatory surgery centers, and professional services based upon Resource Based Relative Value Scale (RBRVS), Medical Severity Diagnosis Related Group (MS-DRG), Ambulatory Payment Classification (APC) or other equivalent scale used by the Centers for Medicare and Medicaid Services, and Delaware geographic adjustments.

1.3.1 The Delaware workers' compensation health care payment system (HCPS) has moved towards an RBRVS, MS-DRG, and APC based system. While the Workers' Compensation Oversight Panel ("Panel") used these tools to form the foundation of the HCPS, Delaware has not adopted by default Medicare rules for workers' compensation. The Panel developed these Delaware specific rules and regulations to govern the HCPS. The HCPS does not support health care service or payment denials based on Medicare rules. The Delaware workers' compensation health care practice guidelines remain in effect and care is presumed compensable when followed. These regulations do not define compensable care, but rather a maximum allowable reimbursement (MAR).

1.3.2 The Delaware workers' compensation regulations supersede when a conflict exists with the Centers for Medicare and Medicaid (CMS) rules.

1.4 Section 2322B(5), Chapter 23, Title 19, Delaware Code authorizes the Workers' Compensation Oversight Panel to establish the amount of reimbursement for a procedure, treatment or service to be a percentage reduction from 85% of the actual charge, if a specific fee is not set forth in the Fee Schedule Amounts. Facility billed codes identified as Add-On and listed as percent of charge shall not be reimbursed more than the reimbursement for the primary code billed by the Facility.

1.5 Section 2322B(9), Chapter 23, Title 19, Delaware Code authorizes and directs the Workers' Compensation Oversight Panel to adopt, recommend, and maintain a formulary and fee methodology for pharmacy services, prescription drugs, and other pharmaceuticals.

1.6 The fees to be established in Sections 2322B shall be promulgated and recommended by the Workers' Compensation Oversight Panel to the Department before the effective date of the regulation.

1.7 Section 2322D, Chapter 23, Title 19, Delaware Code authorizes and directs the Department to adopt by regulation complete rules and regulations relating to Health Care Provider Certification approved and proposed by the Workers' Compensation Oversight Panel.

1.8 Section 2322E, Chapter 23, Title 19, Delaware Code, authorizes and directs the Workers' Compensation Oversight Panel to approve, propose, and recommend to the Department the adoption by regulation of consistent forms for the health care providers and employers ("Forms").

19 Del. Admin. Code § 1341-1.0

11 DE Reg. 920 (01/01/08)
17 DE Reg. 322 (9/1/2013)
18 DE Reg. 577 (1/1/2015)
19 DE Reg. 1100 (6/1/2016)
27 DE Reg. 614 (2/1/2024) (Final)