Claims for Medical Benefits Under the Federal Employees' Compensation Act

DEPARTMENT OF LABOR

Office of Workers' Compensation Programs

20 CFR Part 10

RIN 1215-AA

Claims for Medical Benefits Under the Federal Employees'

Compensation Act

AGENCY: Employment Standards Administration, Office of Workers'

Compensation Programs, Labor.

ACTION: Final rule.

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SUMMARY: On November 24, 1993, the Department of Labor published

proposed revisions to the rules establishing a fee schedule and

procedures for submitting bills for reimbursement for medical

procedures and services provided to injured federal employees under the

Federal Employees' Compensation Act (FECA) (58 FR 62063). The Office of

Workers' Compensation Programs (OWCP) proposed to: Adopt where

applicable the relative value units (RVUs) devised by the Department of

Health and Human Services, Health Care Finance Administration (HCFA),

published most recently on December 2, 1993, 58 FR 63626; eliminate the

requirement to use the Washington State conversion factors; and allow

the use of Geographic Practice Cost Indices (GPCIs) developed by the

Urban Institute for HCFA to determine geographic adjustment factors.

The rules also climate the requirement for original signatures on the

bills.

The comment period closed January 24, 1994, and no comments were

received; the rules are now published in final in the same form as they

were proposed.

EFFECTIVE DATE: April 25, 1994.

FOR FURTHER INFORMATION CONTACT:

Thomas M. Markey, Director for Federal Employees' Compensation,

Employment Standards Administration, U.S. Department of Labor, room S-

3229, Frances Perkins Building, 200 Constitution Avenue, NW.,

Washington, DC 20210; Telephone (202) 523-7552.

SUPPLEMENTARY INFORMATION: The preamble to the proposed rule explained

in detail the background of the schedule of maximum allowable charges

for most medical services provided to injured workers under the Federal

Employees' Compensation Act (FECA), 5 U.S.C. 8101 et seq. See 51 FR

8276, for a complete explanation of the background and purpose of the

schedule.

Under the fee schedule and billing system individual procedures are

assigned a descriptor code using the Physicians' Current Procedural

Terminology (CPT) scheme developed by the American Medical Association.

Each code is then assigned a relative value unit (RVU) reflecting the

relative skill, effort, risk, and time required to perform the

procedure. The maximum allowable amount payable for a given service is

calculated by multiplying the RVU by a conversion factor (CF). This

product is in turn multiplied by a geographic index (GI) which allows

for regional variations in medical costs.

The components of the fee schedule served OWCP well until recently,

when the State of Washington (the system on which several factors of

the fee schedule were based), announced that it was adopting a new fee

schedule based on the newly published Health Care Financing

Administrations (HCFA) RVUs for physicians' services, with

modifications peculiar to Washington State.

Rather than continue to use the Washington State system, the Office

of Workers' Compensation Programs (OWCP) proposed to adopt elements of

the HCFA fee schedule directly. OWCP will continue to use geographic

localities (using Metropolitan Statistical Areas) designed by the Urban

Institute for application of Geographic Practice Cost Indices (GPCIs),

since Medicare pricing localities are carrier specific. Finally, the

conversion factors (see 57 FR 5186) will be changed to accommodate the

change in scale of the relative unit values.

The proposed rules also change the provision requiring that the

medical provider sign the billing form, in order to accommodate the

practice of electronic transmission of medical bills and other similar

practices.

No comments at all were received on the proposed rules.

Accordingly, the proposed changes are being implemented in final

unchanged, except for minor changes to correct grammatical and

typographical errors.

Statutory Authority

5 U.S.C. 8149 provides the general statutory authority for the

Secretary to prescribe rules and regulations necessary for

administration and enforcement of the Federal Employees' Compensation

Act.

5 U.S.C. 8145 provides that the Secretary of Labor shall administer

the Act, may appoint employees to administer it, and may delegate

powers conferred by the Act to any employee of the Department of Labor.

5 U.S.C. 8103 (a) and (b) specifies that the Secretary may approve

or authorize ``necessary and reasonable'' expenses to be paid from the

Employees' Compensation Fund; may issue regulations governing the

provision of services, appliances and supplies; and may prescribe the

form and content of the authorization certificate.

Classification

The Department of Labor has concluded that the regulatory proposal

is not a significant regulatory action under the criteria of section

3(f) of Executive Order 12866.

Paperwork Reduction Act

The information collection requirements entailed by the proposed

regulations have previously been approved by OMB.

Regulatory Flexibility Act

The Department believes that the rule will have ``no significant

economic impact upon a substantial number of small entities'' within

the meaning of section 3(a) of the Regulatory Flexibility Act. Pub. L.

96-354, 91 Stat. 1164 (5 U.S.C. 605(b)). Although this rule will be

applicable to small entities it should not result in or cause any

significant economic impact, since the changes in the method of

calculating the maximum allowable payments will not result in a

significant difference in the outcome from that in the present method.

The Secretary has so certified to the Chief Counsel for Advocacy of the

Small Business Administration. Accordingly, no regulatory impact

analysis is required.

List of Subjects in 20 CFR Part 10

Claims, Government employees, Labor, Workers' compensation.

For the reasons set out in the preamble, part 10 of chapter 1 of

title 20 of the Code of Federal Regulations is amended as follows:

PART 10--CLAIMS FOR COMPENSATION UNDER THE FEDERAL EMPLOYEES'

COMPENSATION ACT, AS AMENDED

1. The authority citation for part 10 is revised to read as

follows:

Authority: 5 U.S.C. 301; Reorganization Plan No. 6 of 1950, 15

FR 3174, 64 Stat. 1263; 5 U.S.C. 8149; Secretary's Order 1-93, 58 FR

21190.

2. Section 10.411 is amended by revising paragraphs (b) and (d)(3)

to read as follows:

10.411 Submission of bills for medical services, appliances and

supplies; limitation on payment for services

* * * * *

(b) By submitting a bill and/or accepting payment, the physician or

other medical provider signifies that the service for which

reimbursement is sought was performed as described and was necessary.

In addition, the physician or other provider thereby agrees to comply

with all rules and regulations set forth in this subchapter concerning

the rendering of treatment and/or the process for seeking reimbursement

for medical services, including the limitation imposed on the amount to

be paid for such services.

* * * * *

(d) * * *

(3) The Director shall assign the relative value units (RVUs)

published by the Health Care Finance Administration (HCFA) to all

services for which HCFA has made assignments, using the most recent

revision. Where there are no RVUs assigned to a procedure, the Director

may develop and assign any that he/she considers to be appropriate

RVUs. The Director will also devise conversion factors for each

category of service, and in devising such factors the Director may

adapt the HCFA conversion factors as appropriate using OWCP processing

experience and internal data. The geographic adjustment factor shall be

that designated by Geographic Practice Cost Indices for Metropolitan

Statistical Areas as devised for HCFA by the Urban Institute and

published February 1, 1991, as Refining the Malpractice Geographic Cost

Index, as updated or revised from time to time.

* * * * *

Signed at Washington, DC, this 15th day of February, 1994.

Shelby Hallmark,

Acting Director, Office of Workers' Compensation Programs.

[FR Doc. 94-4069 Filed 2-22-94; 8:45 am]

BILLING CODE 4510-27-M