In the 2016 Virginia General Assembly session legislation was passed directing the Virginia Workers’ Compensation Commission to establish a fee schedule to pay providers when they treat injured workers. The basis for the schedule is what the providers by geographic area received on average as actual reimbursement in 2015. Dental and oral surgery injuries occur in Workers’ Comp, which means that, starting in January of 2018, dentists and oral and maxillofacial surgeons will be paid what is on the fee schedule promulgated by the compensation commission unless they have a contract with a compensation insurance carrier or TPA.
Furthermore, after January 1, 2018, dentists and oral and maxillofacial surgeons will be paid one of two ways: First, either the amounts on the fee schedule adopted by the Commission or a compensation carrier (Travelers) or a TPA may elect to contract with health care providers and pay them an amount below or above the fee schedule. For example, if Travelers wants to direct volume to one provider, that provider may say instead of getting paid $100 for a procedure, I will take $95 because you are going to send me on average 20 patients per month so the volume offsets the reduction (potentially). In the alternative, if you feel that patients will come to you regardless of the fee, you may say, I am not going to treat compensation claimants because they are burdensome due to too much paper work. The result of this may then result in Travelers wanting to contract with you and pay you $115.
Historically in Virginia and other fee schedule states, the number of compensation insurers and TPAs who elect to contract with a provider at amounts less or above the fee schedule are few and far between. The main reason is that, in health care and dental care, they can more easily predict the types of services patients are going to need on an ongoing basis. Whereas in workers’ compensation, it is hard to predict what jurisdiction the police officer or firefighter will be in when they get a mouth or jaw injury. They know they have 20 of those injuries a year but cannot predict, for example, that two will be in Grundy and eight in Fairfax. So, the easy default is just to pay the fee schedule amount.
A drafted fee schedule should be available for public comment in January 2017. The VDA is closely monitoring the process and will review that draft and be involved in the meetings leading to the final fee schedules that must be in place beginning in January 2018.