SENATE BILL 326

49th legislature - STATE OF NEW MEXICO - first session, 2009

INTRODUCED BY

Stuart Ingle

AN ACT

RELATING TO WORKERS' COMPENSATION; PROVIDING FOR A SCHEDULE OF MAXIMUM ALLOWABLE PAYMENTS FOR HEALTH CARE PROVIDERS.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     Section 1. Section 52-4-5 NMSA 1978 (being Laws 1990 (2nd S.S.), Chapter 2, Section 52, as amended) is amended to read:

     "52-4-5. [FEE] MAXIMUM ALLOWABLE PAYMENT SCHEDULE.--

          A. The director shall adopt and promulgate regulations establishing a schedule of maximum [charges] allowable payments as deemed necessary for treatment or attendance, service, devices, apparatus or medicine provided by a health care provider. The [rates] payments listed in the schedules of maximum [charges] allowable payments shall not fall below the sixtieth percentile or above the eightieth percentile of current [rates for] charges by New Mexico health care providers. In determining current [rates] payments for health care providers, the director shall utilize [a variety of health care provider charges, including the charges of those providers serving low-income, medicare and medicaid patients] New Mexico health care providers workers' compensation related current procedural terminology codes.

          B. A health care provider shall be paid [his] the provider's usual and customary fee for services rendered or the maximum [charge] allowable payment established pursuant to Subsection A of this section, whichever is less. However, in no case shall the usual and customary fee exceed the maximum [charge] allowable payment unless a contractual agreement is made with the employer.

          C. The [fee] maximum allowable payment schedule shall be revised annually by the director utilizing New Mexico health care providers workers' compensation related current procedural terminology codes.

          D. No amount in excess of the amount required by Subsection B of this section for a service shall be paid by the employer, the employer's insurer, the worker, a representative of the worker or any other person to a health care provider for rendering that service in connection with an injury or disablement within the purview of the Workers' Compensation Act or the New Mexico Occupational Disease Disablement Law.

          E. If it is determined by the person primarily responsible for payment that the charges of a health care provider exceed the amount established pursuant to Subsection B of this section or that a health care provider over-utilized or otherwise rendered or ordered inappropriate health care or health care services, and payment is withheld on those grounds, the health care provider may appeal to the director regarding that determination. The director shall establish by regulation procedures for an appeal by a health care provider.

          F. The director shall establish an advisory committee that shall:

                (1) be appointed and serve at the pleasure of the director;

                (2) consist of members, a majority of whom represent health care providers;

                (3) reflect the diversity of authorized licensed health care providers available for workers' compensation and occupational disease disablement cases;

                (4) assist in establishing the schedules of maximum [charges under] allowable payments pursuant to provisions of Subsection A of this section for any fees that are payable to health care providers;

                (5) assist the director in adopting regulations for employers' utilization review procedures and the establishment and conduct of utilization review boards; and

                (6) report its findings, upon request, to the director and the advisory council on workers' compensation and occupational disease disablement.

          G. The schedule of maximum [charges] allowable payments specified in this section shall not apply to hospital charges. The director shall establish a separate schedule of maximum charges for hospital charges no later than April 1, 1991.

          H. Nothing in this section shall prevent an employer from contracting with a health care provider for [fees less than the maximum charges allowable] a negotiated payment structure."

     Section 2. EFFECTIVE DATE.--The effective date of the provisions of this act is July 1, 2009.

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