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Information for Employees

 

How do I report an on-the-job injury?

How do I file a claim?

What medical treatment am I entitled to receive?

How is the compensation rate determined?

Will I get compensated for missing time from work because of my injury?

When are my benefits terminated?

What if the doctor releases me to light duty?

What if I receive an impairment rating or have a scar?

What is a hearing?

Do I get reimbursed for my travel expenses when I go to the doctor?

Can I get a second opinion if I am not happy with the doctor to whom the insurance carrier refers me?

Who sends me my weekly check?

 

Information for Employers

 

Am I required to provide workers' compensation insurance?

Can an employer who is required to have workers' compensation insurance elect NOT to cover its employees?

What are the benefits of workers' compensation insurance for employers and employees?

Who is an employee for workers' compensation purposes?

Are volunteers covered under South Carolina’s Workers’ Compensation Act and covered in the event of an injury?

Can sole proprietors or partners elect to be covered under workers' compensation?

Is the owner of a business or the principal contractor on a job liable for workers' compensation benefits to an employee or subcontractor?

Can an employer require employees to pay for workers' compensation insurance or some of their medical costs?

How are workers' compensation premiums determined?

Can an employer self-insure for workers' compensation?

What is an employer required to do when an accident occurs on the job?

What options does the employer have in case of a disagreement with the injured employee about compensation or medical treatment?

How is compensation determined for an injury?

Who determines whether an individual is an employee for workers' compensation purposes? Who settles disputes over whether an injury occurred on the job?

 

Informal Conferences

What is an informal conference?

What is the purpose of an informal conference?

How long does an informal conference last?

Where is the informal conference held?

What if I can’t attend the conference at the time it is scheduled?

What happens during the informal conference?

How does the Commissioner or the Claims Mediator decide how much I get paid for my injury?

Is the settlement I agree to final?

But what if my injury gets worse after I’ve agreed to a settlement?

What if I don’t agree with the recommendation at the informal conference?

Do I Need A Lawyer?

Where can I get more information?

How do I request an informal conference?

 


 
Medical Treatment

Where do providers mail claims for payment?

When should providers submit claims for payment?

Can Providers submit claim forms to the Commission for processing?

How can providers find correct contact information for insurance carriers?

Can anesthesiologists bill for post-operative pain management?

Can a physician charge separately for anesthesia when the anesthesia is provided by the physician who performs a medical or surgical service?

Can a physician who provides post-operative pain management bill separately for this service?

Can a CPT Code for an E&M visit be billed in conjunction with a surgical code?

Can a physical therapist bill for strapping an ankle?

Can a physician bill for a telephone conversation with a patient to discuss the results of diagnostic testing and/or studies?

Can CPT Code 22612 for arthrodesis be billed twice for the same surgical procedure?

Are Ambulatory Surgery Centers subject to the multiple procedures rule?

What is the MAP for an IME (independent medical evaluation)?

Can a psychologist perform an IME?

When hand surgery is considered a complicated procedure can a request for an IC (individual consideration) be included in the primary procedure code?

Can a physician charge for the use of an operating microscope used for microsurgical or other surgical procedures?

How should services not listed in the fee schedule be billed?

How are supplies and durable medical equipment not listed in the Schedule billed?

What is the reimbursement for medical testimony by deposition of a physician?

Which form(s) should I use to file a request for payment?

When is payment to a medical provider due?

What happens if payment is not made by the Insurance Carrier within 30 days?

Charges for copies of reports and records

Verifying Authorization to Treat between provider and payers

Consultations with Nurse case manager and rehabilitation professionals

Which DRG Edition is currently being used for hospital inpatient prospective payment system (IPPS)?



















Information for Employees

How do I report an on-the-job injury?

Report all injuries at work to your employer immediately and request medical treatment, if needed.  If you neglect to report the injury within 90 days of the accident you may lose your benefits.
 
Although you must report the injury within 90 days, you have up to two years to file a claim for benefits.  If a worker dies because of work-related injuries, the worker’s dependents, or parents if there are no dependents, must file a claim within two years of the death to claim benefits.


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How do I file a claim?

You may personally file a claim if your employer does not report your accident, denies your injury by accident, or if you believe you did not receive all of your benefits.

To file a claim you must submit a
Form 50 or Form 52 to the Commission.  If you are unable to download these forms please contact the Commission’s Claims Department at (803) 737-5723 to request the forms be mailed to you.

When filing a claim on a Form 50 or Form 52, mark the box at the signature line which states "I am filing a claim.  I am not requesting a hearing at this time."

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What medical treatment am I entitled to receive?

You are entitled to all necessary medical treatment that is likely to lessen your disability.  Workers’ compensation generally pays for surgery, hospitalization, medical supplies, prosthetic devices, and prescriptions.  Keep in mind that in order to receive these benefits you must go to the doctor chosen by your employer or its insurance representative.

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How is the compensation rate determined?

You are entitled to compensation at the rate of 66 2/3 percent of your average weekly wage based on the four quarters prior to your injury, but no more than the maximum average weekly wage determined each year by the South Carolina Employment Security Commission.  If you were working two or more jobs at the time of accident, those wages may be included as part of the average weekly wage and compensation rate.

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Will I get compensated for missing time from work because of my injury?

There is a seven-day waiting period before benefits can be paid.  If you are out of work for more than seven days, payments will come from your employer’s insurance representative.  If you are out of work for more than 14 days, you will receive compensation even for the first seven days.

You can expect payments to be made directly to you and these should continue until the doctor releases you to return to work.

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When are my benefits terminated?

After the doctor releases you to return to work with or without restrictions, within 150 days of notification of the accident, you should receive two copies of Form 15 with Section II completed indicating that compensation has been stopped and for what reasons. 

If the insurance carrier stops your compensation, and if you disagree, complete Section III of the Form 15 and send it to the Commission’s Judicial Department.  This is your way to request a hearing to be held in sixty days.

If the Doctor releases you to return to work after the 150-day notification period, your employer or insurance representative will ask you to sign a Form 17, (receipt of compensation ) after you have been back to work for fifteen days.

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What if the doctor releases me to light duty?

You must accept light work if it’s offered.  If you do not accept, all compensation may cease as long as you refuse to return to work.  You have a right to a hearing if you believe that you are not able to do the work assigned to you. 

If you return to light work before you are fully discharged by the doctor at a wage less than you were earning at the time of your original injury, you are entitled to weekly compensation at the rate of the sixty-six and two-thirds (66 2/3%) percent of the difference between your average weekly wage and your new wage.

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What if I receive an impairment rating or have a scar?

When the doctor releases you with an impairment rating or if you have a non-surgical scar that can be seen at least eight feet away, the insurance carrier will request an informal conference/viewing.  This is an opportunity for you to meet with a representative from the commission and the insurance carrier to determine the amount of compensation due.

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What is a hearing?

The workers’ compensation commissioners conduct a hearing to resolve disputes between you and your employer’s representative.  You may apply for a hearing if your employer does not report your accident, denies your injury by accident, or if you believe that you did not receive all your benefits. 

You may download the form to apply for a hearing online or obtain it by contacting the commission’s judicial department at (803) 737-5675 or by email to judical@wcc.sc.gov.

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Do I get reimbursed for my travel expenses when I go to the doctor?

Yes, if the round trip distance is more than ten miles from your home.  You should be reimbursed for the round trip mileage at the rate allowed state employees for mileage.

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Can I get a second opinion if I am not happy with the doctor to whom the insurance carrier refers me?

You can talk to the insurance carrier and see if he or she will allow you to go to another doctor, or you can request a hearing by completing Form 50 and have a Commissioner make a determination on the case.

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Who sends me my weekly check?

Your employer is required to have workers’ compensation insurance if they have four or more employees and the insurance carrier will be responsible to pay compensation to you if you are out of work for more than seven days.

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Information for Employers

Am I required to provide workers' compensation insurance?

Essentially, yes. The rule of thumb is that any employer who regularly employs four or more workers full-time or part-time is required to have workers' compensation insurance. There are some exceptions, including agricultural employees, railroads, and railway express companies and their employees, and employers who had a total annual payroll during the previous year of less than $3,000, regardless of the number of workers employed during that period. Also exempt are Textile Hall Corporation and certain commission paid real estate agents.

Although most employers must purchase workers' compensation insurance, any employer may purchase coverage.

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Can an employer who is required to have workers' compensation insurance elect NOT to cover its employees?

No.

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What are the benefits of workers' compensation insurance for employers and employees?

Workers' compensation pays for a portion of lost wages and medical care provided to employees who are injured on the job. Workers' compensation also compensates employees who suffer permanent disability or disfigurement.

It is a no-fault approach which limits the employer's liability to those benefits provided by the Workers' Compensation Act. It is an inclusive remedy for on-the-job injuries.

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Who is an employee for workers' compensation purposes?

The definition of an employee is quite broad. It includes full-time and part-time workers, adults and minors, and others who have been hired to do certain jobs. The critical test is the degree of control the employer exercises over the worker.

The law also recognizes "statutory employees." These are employees who work for a subcontractor who may be working for a business or another contractor. Employers should inquire whether or not a subcontractor working for them has workers' compensation insurance, regardless of the number of employees employed by the subcontractor. If the subcontractor does not, the subcontractor's injured employees would be covered under the employer's workers' compensation insurance.

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Are volunteers covered under South Carolina’s Workers’ Compensation Act and covered in the event of an injury?

No, unpaid volunteers are considered to be gratuitous employees, and are not subject to the Workers’ Compensation Act.  Organizations that utilize volunteers can obtain coverage / insurance for volunteers.

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Can sole proprietors or partners elect to be covered under workers' compensation?

Yes. Sole proprietors and partners are considered owners of the business and are not automatically included under workers' compensation insurance. They may elect to be covered if they are active in the business and have duly informed their insurance carrier. When a sole proprietorship or partnership incorporates, all employees are automatically covered, including the owners if they are also employees of the corporation.

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Is the owner of a business or the principal contractor on a job liable for workers' compensation benefits to an employee or subcontractor?

Yes. If the subcontractor does not carry workers' compensation insurance, then the owner or the principal contractor would be liable just as if the subcontractor's employee was one of their employees.

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Can an employer require employees to pay for workers' compensation insurance or some of their medical costs?

No. It is illegal to require employees to pay any portion of the premium for workers' compensation insurance or to pay for any medical treatment resulting from a job-related injury.

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How are workers' compensation premiums determined?

To put it in simple terms: how much an employer pays for workers' compensation insurance is determined by the number of employees, their total wages, the type of jobs they perform, and the employer's history of accidents and claims. Insurance companies assign rates to each type of job, charging more to cover riskier jobs. While the rates are regulated by the S.C. Department of Insurance, it is a competitive market and the rates differ for different insurance companies.

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Can an employer self-insure for workers' compensation?

Yes. Hundreds of employers in South Carolina are self-insured. In order to self-insure, an employer must apply, meet certain financial and other requirements, and be approved by the South Carolina Workers' Compensation Commission. An employer may self-insure as an individual organization, or as part of a group self-insurance pool or fund.

Self-insured employers and funds are regulated by the Commission. They are required to maintain reinsurance and a surety bond or letter of credit in an amount specified by the Commission. 

Our
Self-Insurance Division
has more information.

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What is an employer required to do when an accident occurs on the job?

The employer's first obligation is to make sure the employee receives medical attention. The employer is also required to report the injury to the insurance carrier, which reports it to the Commission. Minor injuries, as defined by the Commission, do not have to be reported.

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What options does the employer have in case of a disagreement with the injured employee about compensation or medical treatment?

An employer can request a hearing before a Commissioner, as can the injured employee. This hearing is usually held in the county in which the injury occurred.

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How is compensation determined for an injury?

Workers' compensation pays for necessary medical treatment, loss of wages during the disability, and compensation for permanent disability or disfigurement. If an injured employee is unable to work for more than seven days, the employee is eligible for payment for lost wages. This compensation is limited to two-thirds of the employee's weekly wage, limited to the current weekly wage in South Carolina. If the employee is out of work for more than 14 days, the employee is entitled to compensation from the day of the accident.

The award for total disability or death is limited by law to compensation for 500 weeks. Paraplegics, quadriplegics, and brain-damaged workers are eligible for lifetime benefits. Compensation for partial disability is determined by the Commission from medical reports, testimony of the parties, and the impact of the disability on the injured employee's livelihood.

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Who determines whether an individual is an employee for workers' compensation purposes? Who settles disputes over whether an injury occurred on the job?

The state agency charged with settling disputes such as these and with administering workers' compensation is the South Carolina Workers' Compensation Commission. The Commission is governed by seven commissioners
, each appointed to a six-year term by the Governor with the advice and consent of the Senate.

The commissioners are responsible for hearing and deciding contested cases, for conducting
informal conferences
with employers and employees, and for approving settlements and hearing appeals. A single commissioner hears the case first. The commissioner's decision may be appealed to the full Commission, and in turn to courts at various levels.

The day-to-day operations of the Commission are administered by its executive director. Various departments and divisions within the agency are responsible for its regulatory, administrative and legal functions.


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Informal Conferences


What is an informal conference?
     
An informal conference is an opportunity for you and a representative of your employer’s insurance company to meet with a Commissioner or Claims Mediator to discuss the settlement of your workers’ compensation claim
.

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What is the purpose of an informal conference?
             
The purpose of an informal conference is to reach an agreement on the amount you will be paid if you have any permanent disability or loss of use as a result of an on-the job accident. The agreement will cover any disfigurement or scarring related to the injury. Workers’ compensation pays for disability or loss of use, or on a limited basis, for disfigurement. You cannot be paid for pain and suffering or loss of companionship under workers’ compensation.

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How long does an informal conference last?
           
Usually, about 15 minutes. Please arrive at the conference site early so that you will be ready when your name is called.

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Where is the informal conference held?
           
The conference is usually held in the county where you were injured, or in a nearby county. Before the conference, you will receive a notice that will let you know the date, time, and location of your appointment.

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What if I can’t attend the conference at the time it is scheduled?
           

The informal conference is very important and you should attend. If you cannot attend, contact the Informal Conference Scheduling office (803-737-5734) as soon as possible so that another conference can be scheduled. If you do not keep your appointment and do not contact the commission in advance, you could lose the disability benefits to which you may be entitled.

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What happens during the informal conference?
           
The Commissioner, or more likely a Claims Mediator, will review the doctor’s report of your treatment. You will be asked if the injury limited your physical activities and the Claims Mediator will look at any scars or disfigurement left by the injury. After a brief discussion with you and the insurance representative, the Claims Mediator will recommend a settlement amount.  If you agree, you will be asked to sign an agreement and you will be mailed a check for the settlement amount. You do not have to pay taxes on this amount.

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How does the Commissioner or the Claims Mediator decide how much I get paid for my injury?
           
Your award is based on 66 2/3% of your average weekly pay before taxes and other deductions, up to a maximum amount set under the workers’ compensation law. This is called your compensation rate. In addition, many body parts have been assigned a value measured in weeks of compensation. For example, the complete loss of the use of an arm is valued as 220 weeks of compensation. Depending on the seriousness of your injury, the percent of disability or loss of use agreed to at the conference will be multiplied by the value of the injured body part and your compensation rate. In the earlier example, if we assume that the injured worker has an average weekly wage of $450, the compensation rate would be $300(66 2/3% x $450 = $300). The worker would receive $6600 for an injury that resulted in a 10% loss of use of the arm (10% x 220 weeks x $300 = $6600).

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Is the settlement I agree to final?

Yes. By the time of the conference, all other issues such as medical care and lost wages should be settled between you and the insurance representative. The purpose of the conference is to finalize the agreement over your disability or loss of use.

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But what if my injury gets worse after I’ve agreed to a settlement?
           

If you feel that your injury has worsened, you have one year from the date of the last payment to contact your employer or the insurance company representative to let them know about your concerns. You may be entitled to additional medical treatment or disability payments. If the insurance company refuses to reopen your claim, contact the Workers’ Compensation Commission within the one-year period to file an additional claim.

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What if I don’t agree with the recommendation at the informal conference?
           
If you cannot come to an agreement, your claim automatically will be set for a formal hearing before a Commissioner. The hearing will be held in 3-4 months, and you will get a written notice at least 30 days before the hearing telling you the date, time, and place of the hearing.

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Do I need a lawyer?

You are not required to have a lawyer represent you at the informal conference or hearing. If you do hire a lawyer, you are responsible for paying the lawyer.


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Where can I get more information?
           
Call the Informal Conference Scheduling office of the South Carolina Workers’ Compensation Commission at 803-737-5734; or email Kelly Goodale at
kgoodale@wcc.sc.gov
.   Please have your WCC file number available (seven numbers beginning with last two digits of the year you were injured: WCC 95xxxxx).

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How do I request an informal conference?
           
Write to: Judicial Department, South Carolina Workers’ Compensation Commission, P.O. BOX 1715, Columbia, SC 29202.

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Medical Treatment

Where do providers mail claims for payment?

The original claim for medical services should be sent to the employer and/or insurance carrier (the payer).

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When should providers submit claims for payment?

Claims should be completed and filed with the appropriate payer as soon as possible after the initial visit or treatment and at reasonable and regular intervals throughout the course of treatment.

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Can providers submit claim forms to the Commission for processing?

No. The commission does not accept and will not forward claim forms to employers/insurance carriers.

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How can providers find correct contact information for insurance carriers?

Carrier contact information can be found through the SCWCC website at the following link:

 Verify Coverage Online

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Can anesthesiologists bill for post-operative pain management?

The National Correct Coding Initiative states post operative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by an anesthesiologist unless separate, medically necessary services are required that cannot be rendered by the surgeon. In these cases, the surgeon’s medical record must document the reason the care is being referred to an anesthesiologist.

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Can a physician charge separately for anesthesia when the anesthesia is provided by the physician who performs a medical or surgical service? 

Medicare anesthesia rules disallow separate payment for anesthesia when provided by the physician who performed the service.

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Can a physician who provides post-operative pain management bill separately for this service? 

The service may be reported only if the pain management is unrelated to the operative procedure that was performed.

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Can a CPT Code for an E&M visit be billed in conjunction with a surgical code?

If the service is performed at the time of the initial visit and the service constitutes the major service rendered during the initial visit, the office visit may be identified by modifier 57 to the appropriate level of E&M services with prior authorization by the Insurance Carrier.  When an established patient is scheduled to have the surgical procedure performed during a follow-up office visit, and that service is the primary reason for the visit, payment will be made only for the surgical procedure. An office visit will not be paid for that date of service.

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Can a physical therapist bill for strapping an ankle?

Only the treating physician can bill for strapping an ankle.  

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Can a physician bill for a telephone conversation with a patient to discuss the results of diagnostic testing and/or studies?
 
No.

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Can CPT Code 22612 for arthrodesis be billed twice for the same surgical procedure?

Code 22612 may only be used once. Each additional level should be indicated by Code 22614. Usually, no more than two levels are performed for the same surgery.

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Are Ambulatory Surgery Centers subject to the multiple procedures rule?

Yes. Effective October 1, 2010 Ambulatory surgery centers are to be paid at Medicare's National Average plus 40%.

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What is the Maximum Allowable Payment (MAP) for an independent medical evaluation (IME)? 

Independent Medical Evaluations conducted on or after December 15th 2009 will not be subject to a maximum allowable payment.  However, IME costs will continue to be reviewed in each case and listed on the Form 61 for approval by the Commission.   

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Can a psychologist perform an IME?

An independent medical evaluation (IME) can only be performed by a licensed physician.

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When hand surgery is considered a complicated procedure, can a request for an individual consideration (IC) be included in the primary procedure code?

The request for individual consideration should be addressed and authorized before the surgical procedure is performed, except in the case of an emergency.

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Can a physician charge for the use of an operating microscope used for microsurgical or other surgical procedures?

When a magnifying loupe or magnifying binoculars are used during a surgical procedure, no additional payment will be made.  Only microsurgical techniques requiring the use of operating microscopes may be paid.

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How should services not listed in the fee schedule be billed?

These services are based on the usual and customary charges, and the reimbursement should be negotiated with the insurance company/third party administrator.

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How are supplies and durable medical equipment not listed in the Schedule billed?   

CPT Code 99070: manufacturer’s invoice price plus 20%.

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What is the reimbursement for medical testimony by deposition of a physician?

Use Code 99072 (400.00) to report the initial hour and Code 99073 (100.00) to report each additional quarter hour. Time is measured based on the actual time spent in deposition. Time spent reviewing records is not considered when determining payment.

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Which form(s) should I use to file a request for payment?

For inpatient charges, outpatient facility charges, and ambulatory service center charges, a "UB04" form should be used to request payment.

For physician charges and clinic office-based facilities charges, a "HCFA 1500" Form should be used to request payment.

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When is payment to a medical provider due?

By South Carolina Law, payment to a medical provider must be made within 30 days of the tender of the payment request to the employer's representative. the only exception to the 30-day requirement may occur in very rare cases when the SCWCC has accepted a properly filed request from the payer or provider to resolve a billing dispute. (SC Code of Law 42-9-360; SC Code of Regulations 67-1305).

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What happens if payment is not made by the Insurance Carrier within 30 days?

If payment to a medical provider is not made within 30 days, the payment is considered past due and the provider may seek alternate recourse to obtain payment from the employer's representative.

If the SCWCC finds that an employer's representative routinely delays or refuses payment, the commission may rescind approval of the employer's representative to administer SC Workers' Compensation claims. (SC Code of Regulations 67-1305).

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Charges for copies of reports and records

Providers are required to include supporting documentation when submitting claims, or when required by an insurance carrier, self-insured employer, or the Commission to submit substantiating documentation, and may not charge for these required reports. (See Regulation 67-1302 B(2).) However, when the records or reports are not for the purposes listed above, providers may charge for copying costs. Copying charges are sixty-five cents per page for the first thirty pages and fifty cents per page thereafter, plus a clerical and handling fee of $15 plus tax and actual postage costs. Providers must respond to a request for copies within fourteen days of receipt or face a penalty of up to $200. (SC Code of Law 42-15-95).

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Verifying Authorization to Treat between provider and payers

Medical providers must receive authorization from the employer or insurance carrier prior to providing treatment, except for emergency care when the carrier cannot be reached. An employer who authorizes treatment, whether verbally or in writing, enters into a contract with the provider and is responsible for paying for that service, even if it is determined later than the injury was not work related. When getting authorization every effort should be made to verify as specifically as possible what services the provider is proposing. Whenever possible, approve services by CPT® code(s). If possible obtain written authorization for all treatment. This will help eliminate any possibility of a dispute between the provider and the employer/carrier regarding the review and payment of the bill.

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Consultations with Nurse case manager and rehabilitation professionals

A nurse case manager may bill and be paid only when the consultation service meets all requirements listed in the descriptor of the CPT® consultation code billed. The medical record pertaining to the consultation must specify the time spent in consultation and must be included with the claim for payment. Rehabilitation professionals are coordinators of medical rehabilitation services, including, but not limited to, state, private or carrier based whether on site, telephonic, in or out of state. Rehabilitation professionals are to ensure the primary concern and commitment in each workers' compensation case is to advance the medical rehabilitation of the injured worker. Rehabilitation professionals must comply with S.C. Section 42-15-95 and R 67-1308 when communicating with a health care provider who provides examination or treatment for any injury, disease, or condition for which compensation is sought. Rehabilitation professionals shall be subject to the requirements, rules, regulations, and Code of Ethics specific to their license and certification.

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Which DRG Edition is currently being used for hospital inpatient prospective payment system (IPPS)?

The new MS-DRG Grouper, Version 31.0, is effective for discharges on or after October 1, 2013.

 

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