A complete workers comp price list from North Carolina

Filed Under: Costs, Health plans, Patients

Wonk alert!

Anyone who knows us knows how much we love price lists.

Here’s a new one: It’s a site that gives access to a full workers comp price list for North Carolina, called the “N.C. Industrial Commission Medical Fee Schedule.”

You can download a spreadsheet that has the prices for workers comp settlements for North Carolina for what looks like the entire Healthcare Common Procedure Coding System (HCPCS, often pronounced “hick picks”) totaling 17,022 items.

The spreadsheet lists prices based apparently on Medicare rates, and also gives both facility and non-facility pay rates. Interestingly, they’re the same for many procedures.

It also gives codes for durable medical equipment. The descriptions are sketchy — our favorite 72148, MRI of the lower back without contrast — is listed as “radiology,” so we are guessing there is some additional spreadsheet that’s not visible to us.

Medicare pays $403 for that MRI across North Carolina, while workers comp pays $419.23 for both facility and non-facility providers. The add-ons like “technical component” and a reading fee are not included in this rate. (Eyeglazing detail can be found here.)

It’s a ton of data, and it’s a pretty interesting look at payments via workers comp, which is widely described as one of the most lucrative places for hospitals and doctors to look for payments. It’s also a place rife with fraud and finagling, judging from the anecdotes we’ve heard.

Here’s detail on the methodology from the site. If you love pricing data, you’ll be interested in this.

“11 NCAC 23J .0103 FEES FOR INSTITUTIONAL SERVICES
(a) Except where otherwise provided, maximum allowable amounts for inpatient and outpatient institutional services
shall be based on the current federal fiscal year’s facility-specific Medicare rate established for each institutional
facility by the Centers for Medicare & Medicaid Services (“CMS”). “Facility-specific” rate means the all-inclusive
amount eligible for payment by Medicare for a claim, excluding pass-through payments. An institutional facility may
only be reimbursed for hospital outpatient institutional services pursuant to this Paragraph and Paragraphs (c), (d), and
(f) of this Rule if it qualifies for payment by CMS as an outpatient hospital.

(b) The schedule of maximum reimbursement rates for hospital inpatient institutional services is as follows:
(1) Beginning April 1, 2015, 190 percent of the hospital’s Medicare facility-specific amount.
(2) Beginning January 1, 2016, 180 percent of the hospital’s Medicare facility-specific amount.
(3) Beginning January 1, 2017, 160 percent of the hospital’s Medicare facility-specific amount.

(c) The schedule of maximum reimbursement rates for hospital outpatient institutional services is as follows:
(1) Beginning April 1, 2015, 220 percent of the hospital’s Medicare facility-specific amount.
(2) Beginning January 1, 2016, 210 percent of the hospital’s Medicare facility-specific amount.
(3) Beginning January 1, 2017, 200 percent of the hospital’s Medicare facility-specific amount. “