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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: Department of Labor, Division
of Industrial Affairs, Office of Workers' Compensation
Contact Information:
John F. Kirk, Administrator - Office of Workers' Compensation
News & Updates:
Subscribe to OWC E-mail Updates
Other:
HealthCare Payment System Main Page
See: Introduction and Fee
Schedule Guidelines, Fee Schedule Data & Guidelines
Health Care Practice Guidelines
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | Not applicable | Fee schedule not tied to conversion factor | |
| What is the basis of the fee schedule for outpatient therapy services? | Other | Ninety percent (90%) of the 75th percentile of actual charges within the geozip where the service or treatment is rendered (Title 19: 1341 Workers' Compensation Regulations, 4.4.1) | http://dowc.ingenix.com/info.asp?page=rules#44 |
| Are there limits on the number of physical therapy visits allowed? | Yes | Varies; see DE practice guidelines | http://dowc.ingenix.com/info.asp?page=pracguid |
| Are there limits on payment per visit for outpatient therapy services? | No | No regulations identified | |
| Do regulations require use of treatment guidelines? | Yes | 7 DE practice guidelines (CTS, Chronic Pain, CTD, Low back, Shoulder, Cervical spine, Lower extremity) | http://dowc.ingenix.com/info.asp?page=pracguid |
| Is a referral required in order to see a physical therapist? | No | Certification is required in order to treat under the Delaware's WC Statute, without the requirement for prior authorization. | http://dia.delawareworks.com/workers-comp/hcps/provider-certification.php |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | Rate negotiated in contract shall prevail (Title 18/1342 WC regulations, section 4.4.1) | http://dowc.ingenix.com/info.asp?page=rules#428 |
| Can the injured worker be charged for any claim-related services? | No | Title 19 Del. C. §2322F(l) Balance billing prohibited. | http://delcode.delaware.gov/title19/c023/sc02/index.shtml |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | ||
| Are there provider network and/or managed care regulations in place? | No | ||
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | Title 19 Del.C. § 2322B(6): Per fee schedule if provider licensed or permitted to provide procedure in Delaware; if not licensed or permitted in Delaware, greater of provider's state WC fee schedule or DE fee schedule for geozip where injury occurred (or employee principally assigned) | http://delcode.delaware.gov/title19/c023/sc02/index.shtml |
| 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) - No