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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 Administration (WCA)
Contact Information:
New Mexico WCA contacts
News & Updates:
See "News and
Announcements" on the WCA home page
Other:
Health
care providers' home page
Health Care Provider's Guide
New Mexico WC Statutes (Chapter 52)
Therapy Regulations
Question | Response | Detail | Citation |
What is the conversion factor for outpatient therapy services? | Not applicable | Schedule of maximum fees provided | www.workerscomp.state.nm.us/hcp_fee.php |
What is the basis of the fee schedule for outpatient therapy services? | Other | Maximum rates within 60th and 80th percentile of current rates | Designing Workers' Compensation Medical Fee Schedules (WCRI report WC-12-19, June 2012) |
Are there limits on the number of physical therapy visits allowed? | No | §52-1-49 requires employer to provide worker with timely, reasonable and necessary health care services…as long as treatment is necessary. Use left navigation in website to locate statute | www.conwaygreene.com/nmsu/lpext.dll?f=templates&fn=main-h.htm&2.0 |
Are there limits on payment per visit for outpatient therapy services? | Yes | Rule 11.4.7.9 E.(17)(b) Procedures for establishing maximum amount of reimbursement due: "may include all codes which are reasonable and necessary…in a single day" | www.nmcpr.state.nm.us/nmac/parts/title11/11.004.0007.htm |
Do regulations require use of treatment guidelines? | Yes | Official Disability Guidelines, effective 1/1/2013 See 11.4.7.8(F) of Title 11, Chapter 4, Part 7 | Treatment rendered pursuant to ODG is presumed reasonable and necessary |
www.workerscomp.state.nm.us/pdf/rules/rule7.pdf www.nmcpr.state.nm.us/nmac/parts/title11/11.004.0007.htm |
Is a referral required in order to see a physical therapist? | No | Physical therapist recognized as treating provider, not subject to 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 | 11.4.7.8 General Provisions (C) of WCA Rules "Nothing in these rules shall preclude the separate negotiation of fees between a practitioner and a payer within the health care provider fee schedule for any health care service as set forth in these rules." | www.nmcpr.state.nm.us/nmac/parts/title11/11.004.0007.htm |
Can the injured worker be charged for any claim-related services? | Yes | Balance billing is addressed on page 35 of the Health Care Providers Guide (cannot balance bill patient for covered injury/condition). See NMAC 11.4.7.E (17 and 18) for information about missed new patient appointments. |
www.workerscomp.state.nm.us/partners/hcp_pdf/hcp_guide.pdf www.nmcpr.state.nm.us/nmac/parts/title11/11.004.0007.htm |
Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | Defaults to state practice act | |
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 | NMAC 11.4.7.9(G) addresses qualification of out of state providers | www.nmcpr.state.nm.us/nmac/parts/title11/11.004.0007.htm |
Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | Section 5 §52-1-26.4 | www.workerscomp.state.nm.us/partners/hcp_pdf/hcp_guide.pdf |
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 - Yes
Exclusive State Fund - No
State Comp Fund (last resort) - No