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Personal injury protection (PIP) information for insurers and providers

ORS 742.525 prohibits health care providers from billing persons who receive personal injury protection benefits more than they charge the general public or an amount that exceeds the fee schedules for medical and other services published under Oregon workers' compensation laws.

Insurers and health care providers can use the links below to find more information about the workers' compensation fee schedules.

New law will adjust benefits, reimbursements beginning in 2006

Governor Kulongoski recently signed Senate Bill 151, which makes adjustments to PIP benefits and hospital reimbursements effective January 1, 2006. Among the changes, SB 151, establishes a separate alternative measure for payment of hospital services, replacing the standard that applies to payment for medical services generally.  The general standard, enacted in 2003, ties PIP reimbursements to the workers compensation fee schedule.  This change will allow a more complete reimbursement of hospital expenses.

Current workers' compensation fee schedules

Claims should be paid using the workers' compensation fee schedule in effect when the medical service was provided. The fee schedule changes April 1 each year.

The cost/charge ratios for hospitals are revised April 1 and October 1 of each year.

Oregon workers' compensation fee rules fact sheet and billing examples

Hospital claim payment procedures

Insurance Division Bulletin INS 2003-7

Reimbursement restrictions on fees versus limitation on services or benefits

Insurance Division Bulletin 2003-7 (re-issued February 13, 2004) states that application of the workers' compensation fee schedules for PIP benefits is limited to the specific fees and does not include restrictions in the rules on services and benefits. For example, insurers should not restrict reimbursement under the related rules for the 30-day/12-visit period or apply the payment limit of 3 CPT codes per day. (These service and benefit restrictions are found in OAR 436-010-0005 (2)(c) and 436-009-0050 (7)(b) respectively.)

Conversion factors for specific CPT codes

Several questions have arisen on the appropriate fee schedule conversion factor for chiropractic services under CPT codes 98940 though 98943. These particular treatment codes are to be calculated under the conversion factors for the medicine service category, not physical medicine.

Questions?

Please contact Cliff Nolen, 503-947-7221.

 

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This document was last revised on August 31, 2005 .