W. Va. Code R. § 85-15-10

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 85-15-10 - Payment for Physical and Vocational Rehabilitation Services

10.1. The Commission or Insurance Commissioner, private carrier or self-insured employer whichever is applicable, will pay for physical and vocational rehabilitation services in accordance with the fee schedule in effect at the time the service is rendered, adopted by the Commission or Insurance Commissioner, whichever is applicable, pursuant to W. Va. Code § 23-4-3 and otherwise as set forth in this rule. To the extent there are inconsistencies between the fee schedule and this rule, this rule shall govern. Only those physical rehabilitation services that are reasonable and necessary, in the sole discretion of the Commission, within the scope of the applicable rehabilitation plan, and otherwise meet the standards as outlined in Sections 3.7 and 2.2.b of this Rule and 85 C.S.R. 27, can be reimbursed pursuant to these rules.

10.2. Unless otherwise specified in a contractual agreement with a provider, the following services are considered overhead and the Commission or Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, will not pay for these services:

a. Administrative and supervisory salaries and related personnel expenses;

b. Office rent;

c. Depreciation;

d. Office equipment purchase and rental;

e. Telephone expense including long distance phone call charges;

f. Postage

g. Shipping;

h. Expendable supplies;

i. Printing costs;

j. Copier costs;

k. Printing of fiche and department electronic files;

l. Maintenance and repair;

m. Taxes;

n. Automobile costs, maintenance, and mileage;

o. Insurance;

p. Dues and subscriptions;

q. Vacation, sick leave, and other expenses of a similar nature;

r. Internal staffing time;

s. Filing of material in case files;

t. Setting up files;

u. Activities associated with reports other than composing or dictating complete draft of the report (e.g., editing, filing, distribution, revising, typing, mailing, and any other related time spent by the vocational rehabilitation service provider reviewing the work of a qualified rehabilitation provider shall not be paid)

v. Generating and keeping internal record keeping forms;

w. Time spent on any administrative and clerical activity, including typing, copying, mailing, distributing, filing, payroll, record keeping, delivering mail, and picking up mail. This does not prohibit reimbursement for actual time spent writing/typing reports to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable.

x. Activities associated with counselors training, general discussions regarding office procedures, internal case file reviews by supervisors, meetings, and seminars;

y. Unanswered phone calls;

z. Any other item or service not specifically identified and separately billed;

aa. No payment will be made for reports prepared by physicians and submitted through the counselor; and

bb. No payment will be made for any activity after notification by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, of case closure or plan termination, unless a closure report is requested at which time only those charges directly related to the preparation of the closure report will be approved.

cc. Upon termination of the Commission, self-insured employers and private carriers may contract for physical and vocational rehabilitation services with providers for fees greater or less than those contained in the fee schedule.

10.3. Any bill submitted to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, must include the following information:

a. Claimant's name;

b. Claimant's claim number

c. Claimant's social security number;

d. Dates of service;

e. Place of service;

f. Type of service;

g. Appropriate procedure code(s);

h. Charge, which must be broken down into 1/10th of an hour (6 minute) increments;

i. Total bill charge;

j. The name and unique identification number, if the provider has been assigned a number by the Commission or the Insurance Commissioner, of the qualified rehabilitation provider rendering the service;

k. Vendor number;

l. Date of billing;

m. An itemization of bills on Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, approved forms;

10.4. The expenditure for vocational rehabilitation shall not exceed twenty thousand dollars ($20,000) for any one injured employee. All services approved by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, as part of a rehabilitation plan, or the development thereof, shall be included in the twenty thousand dollar ($20,000) limitation, including, but not limited to, the following:

a. Vocational or on the job training;

b. Counseling, including all services rendered by a vocational rehabilitation service provider and a qualified rehabilitation professional. Counseling provided by psychiatrist or psychologists shall not be included within the $20,000 limitation. QRP charges for dates of service on or before May 5, 2004, shall not be included within the $20,000 limitation;

c. Assistance in obtaining appropriate temporary or permanent work site, work duties or work hours modification;

d. Job placement services;

e. Other services approved in the sole discretion of the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable.

10.5. Temporary total disability benefits, temporary partial rehabilitation benefits, and physical rehabilitation services are not to be included in the twenty thousand ($20,000.00) dollar limitation.

10.6. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, cannot reimburse providers for physical rehabilitation services which require prior authorization under the provisions of W. Va. Code § 23-4-3, or any rule adopted there under, unless the physical rehabilitation services provider obtains prior authorization.

10.7. In order to obtain reimbursement for services rendered, including the costs of medicines and mechanical appliances or devices, physical and vocational rehabilitation services providers must submit a verified statement on forms (including in electronic format) prescribed by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable. The forms must be filed with the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, within six (6) months after the service is provided or the medicines, mechanical appliances or devices are delivered. Failure to timely submit a reimbursement form bars the provider from any right of recovery from the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, or any other party including, among others, the injured worker, the applicable employer, or any of their third party health care insurers.

10.8. All physical and vocational rehabilitation service providers are prohibited from making any charge against an injured worker or any other person, firm or corporation for any service rendered as a part of a rehabilitation plan or as a result of a compensable injury. Nothing in this section prevents another agency of any governmental unit, person, firm, corporation, or other entity from agreeing to reimburse a service provider for services rendered.

10.9. In the event that an injured worker insists upon the delivery of a physical and/or vocational rehabilitation service after being advised in writing by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, that the service has been determined not to be medically, physically, or vocationally necessary, the provider may charge the injured worker for the costs of such service notwithstanding the provisions of section 10.8, but only if the provider first informs the injured worker that he or she will be personally responsible for the costs of the service and informs the injured worker as to the amount of the charge. If the injured worker has other health care insurance which will pay for the service described in this section, then the provider may bill that insurer for the service and no provision of these rules prevents the provider from receiving reimbursement under the terms of the insurance policy.

10.10. "Without limiting the general nature of various statutes respecting criminal fraud, and by way of illustration and not in limitation, the following are deemed unlawful acts and practices:

a. Billing for services not actually performed;

b. Billing for expenses not actually incurred;

c. Billing with incorrect dates of service;

d. Offering consideration of any kind, including gifts, services or gratuities to Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, employees in exchange for or as a past reward for referring cases to the provider;

e. Failing to close claims for rehabilitation services at the earliest practicable date when the claimant can no longer benefit from such services. The rehabilitation professional will be consulted before the claim is closed for the purpose of determining the earliest practicable date of closure;

f. Providing false information in any statement to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable,, or forging or falsifying any record required to be kept by these Rules or any other statute or rule governing providers; and g. "Rolling in" unreimbursable time or expenses by adding hours to billable time or expenses.

10.11. All providers and employers shall retain for five (5) years and provide to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, on request and without a subpoena hard copies of the source underlying any bill, invoice, report, etc. submitted to the Fund Commission, Insurance Commissioner, private carrier or self-insured employer by electronic or other means.

W. Va. Code R. § 85-15-10