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This summary sets forth various workers' compensation regulations regarding outpatient physical therapy services. The Workers' Compensation State Regulations resource may serve as a tool to assist in locating regulations. Please send database comments and corrections to advocacy@apta.org.
To the extent an individual or entity wishes to rely upon information contained in this resource, such reliance should be based upon an independent legal review and analysis of applicable law. This resource was prepared for informational purposes only and is not offered or intended, nor should it be relied upon, for legal advice for any specific set of circumstances. Additional legal doctrines, federal and state statutes, and case law not set forth herein may apply to your situation and such laws, rules and regulations can vary from state to state. You should consult with your own attorney to obtain specific legal advice on your particular facts and circumstances and applicable laws, rules and regulations.
Key Resources/Links
Agency:
Workers' Compensation Board
Contact information:
Maine WCB Contacts
Office of Medical Rehabilitation Services 201/941-4557
News & Updates:
Subscribe to WCB ENews
Subscribe to WCB ListServe
Other:
Office of Medical Rehab Services
Medical Fee Schedule
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | Not reported | Schedule of maximum fees provided | Schedule of maximum fees available from Office of Medical Rehab Services page |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | Sections 2.01 and 2.02, medical fee schedule | www.maine.gov/sos/cec/rules/90/90/351/351c005.doc |
| Are there limits on the number of physical therapy visits allowed? | No | Based on medical necessity | Workers' Compensation Medical Cost Containment: A National Inventory, 2011 (WCRI report WC-11-35, April 2011) |
| Are there limits on payment per visit for outpatient therapy services? | No | ||
| Do regulations require use of treatment guidelines? | Yes ** | Outdated AHCPR for low back; state-specific for carpal tunnel ** Workers Compensation Board has considered eliminating these guidelines because they are out-dated. |
www.maine.gov/wcb/departments/omrs/omrs/ur.htm |
| Is a referral required in order to see a physical therapist? | No * | PT recognized as treating provider, not subject to referral * However, an employer is not obligated to pay for services without the referral. |
Workers' Compensation Medical Cost Containment: A National Inventory, 2011 (WCRI report WC-11-35, April 2011) |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes - | Employer/insurer must provide written notice to health care provider if requested fee adjusted, including reason for adjustment (unless reduced to fee schedule maximum). Notification shall be made at the time the fee is paid. Section 1.06, Billing Procedures, of Chapter 5, Medical Fee Schedule | 39-A M.R.S.A. §209 www.maine.gov/sos/cec/rules/90/chaps90-.htm |
| Can the injured worker be charged for any claim-related services? | No | See Section 1.06 (5), Billing Procedures, of Chapter 5, Medical Fee Schedule | www.maine.gov/sos/cec/rules/90/chaps90-.htm |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | The Standard for Supervision of Physical Therapist Assistants and Physical Therapy Aides and the PT Practice Act would rule. | PT Practice Act and Rules: www.state.me.us/pfr/professionallicensing/professions/physical_therapists/index.htm Standards for Supervision rules: www.maine.gov/sos/cec/rules/02/chaps02.htm#393 |
| Are there provider network and/or managed care regulations in place? | No | Managed care regulations for Preferred Provider Organizations under Group Health Plans do not apply to workers’ compensation "networks" or "PPOs," but other statutes and regulations may apply, depending on what the network does. For instance, Utilization Review Entities must be certified or approved by the Workers' Compensation Board and adjustors must have a license and comply with statutes and rules for adjusting claims. Therefore a "network" or "PPO" managing workers compensation claims cannot adjust or review claims without the appropriate license(s). In addition, employers/workers' compensation carriers cannot direct where injured employees go for medical care beyond the 10th day after the injury (not the 10th day after the referral). | 39-A M.R.S.A. §210 – Medical Utilization Review A list of approved UR Providers can be found at www.maine.gov/wcb/departments/omrs/omrs/ur.htm See 90-351 Maine Workers Compensation Board Rules, Chapter 7 for Utilization Review Rules (available at www.maine.gov/wcb/rules/RulesAndRegs.htm) 39-A M.R.S.A. §206 – Duties and rights of parties as to medical and other services; cost |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Unknown | ||
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | No |
1 While some states use a mandatory fee schedule, many states have provisions for fees to be negotiated above or below the published fee schedule. "Yes + / - " indicates that fees can be negotiated above or below the fee schedule. "Yes -" indicates that fees can only be negotiated below the fee schedule.
The following payer types conduct business in this state.
Private Carriers - Yes
Self-insured Employers or Groups - Yes
Competitive State Fund - No
Exclusive State Fund - No
State Comp Fund (last resort) - Yes