GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1997

S	1 

SENATE BILL 914

Short Title:  Workers' Comp. Hospital Charges.	(Public)

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Sponsors: Senators Kerr; Cooper and Hoyle.

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Referred to:  Commerce.

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April 17, 1997

A BILL TO BE ENTITLED
AN ACT TO REVISE THE REIMBURSEMENT METHODOLOGY FOR HOSPITAL CHARGES UNDER WORKERS' COMPENSATION.
The General Assembly of North Carolina enacts: Section 1.  G.S. 97-26(b) reads as rewritten:
"(b) (Effective June 30, 1997 – see editor's note) Hospital Fees. –Each hospital subject to the provisions of this subsection shall be reimbursed the amount provided for in this subsection unless it has agreed under contract with the insurer, managed care organization, employer (or other payor obligated to reimburse for inpatient hospital services rendered under this Chapter) to accept a different amount or reimbursement methodology.
Except as otherwise provided herein, payment for medical treatment and services rendered to workers' compensation patients by a hospital shall be equal to the payment the hospital is authorized to receive for the same treatment or service under the State Plan, provided that:
(1)	Payment for inpatient hospital inpatient services provided on or after July 1, 1997, and on or before December 31, 1997, shall not be less than a minimum of ninety percent (90%) nor more than a maximum of one hundred percent (100%) of the hospital's itemized charges as shown on the UB-92 claim form.
(2)	Payment for inpatient hospital services provided on or after January 1, 1998, through and including December 31, 1998, shall be not more than a maximum of one hundred percent (100%) of the hospital's itemized charges as shown on the UB-92 claim form nor less than a minimum percentage of such charges that the Commission determines would have been required to have produced an average payment rate equal to ninety-three and one-tenth percent (93.1%) of aggregate charges for all inpatient claims processed by the Commission during the fiscal year ending June 30, 1997.
(3)	Payment for inpatient hospital services provided on or after January 1, 1999, shall be annually established by the commission as follows:
a.	Beginning in the third quarter (July, August, and September) of 1998, and annually thereafter, the Commission shall review data from the State Plan to ascertain the aggregate hospital itemized charges and aggregate amounts authorized for payment by the State Plan (including payments actually made by the State Plan and deductible, coinsurance, or other amounts for which the patient/insurer may have been liable for inpatient hospital claims paid to participating hospitals by the State Plan during the immediately preceding fiscal year ending June 30.  The Commission shall then utilize the data described in the preceding sentence to calculate the extent, if any, to which aggregate State Plan authorized payments were less than aggregate charges on inpatient hospital claims paid by the State Plan during the preceding fiscal year.
b.	Beginning in the third quarter (July, August, and September) of 1998, and annually thereafter, the Commission shall calculate aggregate hospital itemized charges and aggregate payments authorized by the Commission on all inpatient hospital workers' compensation claims approved for payment by the Commission during the preceding fiscal year ending June 30.
c.	Based on the data described in sub-subdivisions a. and b. of this subdivision, the Commission shall on or before December 1, 1998, and December 1 of each subsequent year adopt modifications if and to the extent required to the minimum percentage described in subdivision (1) of this subsection to annually establish a payment rate for inpatient workers' compensation cases that in the aggregate bears a percentage relationship to hospital itemized charges that is equal to the State Plan relationship between aggregate payments authorized and aggregate itemized charges for claims paid by the State Plan during the preceding fiscal year ending June 30.  Any such modification shall be effective for the next succeeding calendar year beginning January 1 of such year.
Notwithstanding any other provisions of law, the Commission's determination of payment rates under this subsection shall:
(1)	Comply with the procedures for adoption of a fee schedule established in G.S. 97-26(a);
(2)	Include publication on or before October 1 of each year of the proposed payment rate, and a summary of the data and calculations on which the rate is based;
(3)	Be deemed to constitute a final permanent rule under Article 2A of Chapter 150B;
(4)	Be subject to the declaratory ruling provisions of G.S. 150B-4; and
(5)	Be subject to judicial review under Article 4 of Chapter 150B of the General Statutes.
Payment for a particular type of medical compensation that is not covered under the State Plan shall be based on the allowable charge under the State Plan for comparable services or treatment, as determined by the Commission.
A hospital's itemized charges on the UB-92 claim form for workers' compensation services shall be the same as itemized charges for like services for all other payers."
Section 2.  This act becomes effective July 1, 1997.