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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:
Offices of the Insurance Commissioner, Workers' Compensation
Contact Information:
E-mail WV Workers' Compensation
News & Updates:
See "Notices and Other Information" on home page
Other:
Rules - Search "Title Series" for 85-15 (Vocational and physical rehabilitation), and 85-20 (Medical management)
Fee Schedule
Therapy Regulations
Question | Response | Detail | Citation |
What is the conversion factor for outpatient therapy services? | 135% of Medicare | 135% of Medicare per RBRVS based procedures document | www.wvinsurance.gov/Default.aspx?tabid=372 |
What is the basis of the fee schedule for outpatient therapy services? | RBRVS | See Detail Reference Guide to Determining CMS Medicare +35% | www.wvinsurance.gov/LinkClick.aspx?fileticket=Kt5uPjIel4U%3d&tabid=372&mid=994 |
Are there limits on the number of physical therapy visits allowed? | Yes | §85-20-46. Treatment Guidelines: Physical Medicine, section 46.2. Up to 10 visits in the initial 14 days. No more than16 in the 1st 30 days/12 the 2nd 30 days. Treatment in excess of the above requires prior review and authorization per §85-20-9. Coverage and Billing Provisions section 9.10.h |
www.wvinsurance.gov/LinkClick.aspx?fileticket=IoXHcc-ihrc%3d&tabid=330&mid=899 |
Are there limits on payment per visit for outpatient therapy services? | No | ||
Do regulations require use of treatment guidelines? | Yes | §85-20 IV. SPECIFIC TREATMENT GUIDELINES (search Title-Series 85-20, select the active document, section IV starts on page 23) | http://apps.sos.wv.gov/adlaw/csr/ |
Is a referral required in order to see a physical therapist? | Yes | ||
Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | 85CSR20-5.7.a.1 fees can be negotiated; Managed Care Health Plans are exempt from max. fees (can pay more) (search Title-Series 85-20, select the active document) | http://apps.sos.wv.gov/adlaw/csr/ www.wvinsurance.gov/WorkersCompensation/WCManagedHealthCarePlansFeesschedule/Schedule.aspx |
Can the injured worker be charged for any claim-related services? | No | ||
Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | Default to state practice act | |
Are there provider network and/or managed care regulations in place? | Yes | Legislative Rule Title 85 CSR, Series 21 | www.wvinsurance.gov/WorkersCompensation/WCManagedHealthCarePlansFeesschedule.aspx |
Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | WV fee schedule applies unless injured worker is part of Managed Health Care Plan and seeks treatment from a provider under a PPO arrangement with the carrier. | |
Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | Rule §85-20-34 (search Title-Series 85-20, select the active document) |
http://apps.sos.wv.gov/adlaw/csr/ |
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