Three Problems Caused by Maryland’s Medical Fee Guide for Workers’ Compensation Claims

By Clifford B. Sobin, Esq.

The Workers’ Compensation Commission regulates the amount a Maryland medical provider can charge for treating work related injuries. The permitted amounts are found in a document entitled, “Guide of Medical and Surgical Fees”. The medical provider may not charge the injured worker an amount in excess of the amount provided in the fee guide.

These rules cause difficulties in three areas:

1) When the treatment is out of state. In that case, Maryland fee guides do not restrict the health care provider from charging whatever they want. Nevertheless, the workers’ compensation insurance company will only pay an amount called for in the fee guide – the injured worker is stuck for the difference. Although the statute permits the Commission to Order a higher payment when special circumstances permit, it almost always declines to do so. Therefore, it is crucial that an injured employee explicitly obtain the agreement of the out of state health care provider to accept the fee schedule before becoming a patient.

2) When the claim is initially denied. If the workers’ compensation insurance company denies a claim, usually if there is a medical insurer, bills will be paid by the medical insurer while a hearing is pending. As a result the claimant may pay a deductible and the health insurer will pay pursuant to its fee schedule. Problems can occur when the claim subsequently becomes compensable. This may result in:

1. payments being yanked from the medical provider by the health insurer; or
2. issues concerning who reimburses the claimant for co-pay expenses (health care provider or workers’ compensation insurer) as well as what happens if the medical insurer has paid more to the health care provider than the fee schedule permits.

3) Difficulty in finding medical providers. Many physicians, especially orthopedic surgeons and neurosurgeons, are refusing to accept patients who rely on workers’ compensation insurers to pay for the medical treatment. This is due to the reduced rates, increased documentation, and uncertainty or delay of payment which is part and parcel to administering a workers’ compensation claim.

Please do not hesitate to contact us at Berman | Sobin | Gross LLP in order to assist you in these matters