656.248
Medical service fee schedules; basis of fees; application to service provided
by managed care organization; resolution of fee disputes; rules. (1) The Director of the Department
of Consumer and Business Services, in compliance with ORS 656.794 and ORS
chapter 183, shall promulgate rules for developing and publishing fee schedules
for medical services provided under this chapter. These schedules shall
represent the reimbursement generally received for the services provided. Where
applicable, and to the extent the director determines practicable, these fee
schedules shall be based upon any one or all of the following:
(a) The current
procedural codes and relative value units of the Department of Health and Human
Services Medicare Fee Schedules for all medical service provider services
included therein;
(b) The average
rates of fee schedules of the Oregon health insurance industry;
(c) A reasonable
rate of markup for the sale of medical devices or other medical services;
(d) A commonly
used and accepted medical service fee schedule; or
(e) The actual
cost of providing medical services.
(2) Medical fees
equal to or less than the fee schedules published under this section shall be
paid when the vendor submits a billing for medical services. In no event shall
that portion of a medical fee be paid that exceeds the schedules.
(3) In no event
shall a provider charge more than the provider charges to the general public.
(4) If no fee has
been established for a given service or procedure the director may, in
compliance with ORS 656.794 and ORS chapter 183, promulgate a reasonable rate,
which shall be the same within any given area for all primary health care
providers to be paid for that service or procedure.
(5) At the
request of the director and in the method and manner prescribed by rule, all
providers of health insurance, as defined by ORS 731.162, shall cooperate and
consult with the director in providing information reasonably necessary and
available to develop the fee schedules prescribed under subsection (1) of this
section. A provider shall not be required to provide information or data that
the provider deems proprietary or confidential. However, the information
provided shall be considered proprietary and shall not be released by the
director. The director shall not require such information from a health
insurance provider more than once per year and shall reimburse the provider’s
costs for providing the required information.
(6)
Notwithstanding subsection (1) or (2) of this section, such rates or fees
provided in subsections (1) and (2) of this section shall be adequate to insure
at all times to the injured workers the standard of services and care intended
by this chapter.
(7) The director
shall update the schedule required by subsection (1) of this section annually.
As appropriate and applicable, the update shall be based upon:
(a) A
statistically valid survey by the director of medical service fees or markups;
(b) That
information provided to the director by any person or state agency having
access to medical service fee information;
(c) That
information provided to the director pursuant to subsection (5) of this
section; or
(d) The annual
percentage increase or decrease in the physician’s services component of the
national Consumer Price Index published by the Bureau of Labor Statistics of
the United States Department of Labor.
(8) The director
is prohibited from adopting or administering rules which treat manipulation,
when performed by an osteopathic physician, as anything other than a separate
therapeutic procedure which is paid in addition to other services or office
visits.
(9) The director
may, by rule, establish a fee schedule for reimbursement for specific hospital
services based upon the actual cost of providing the services.
(10) A medical
service provider is not authorized to charge a fee for preparing or submitting
a medical report form required by the director under this chapter.
(11)
Notwithstanding any other provision of this section, fee schedules for medical
services and hospital services shall apply to those services performed by a
managed care organization certified pursuant to ORS 656.260, unless otherwise
provided in the managed care contract.
(12) When a
dispute exists between an injured worker, insurer or self-insured employer and
a medical service provider regarding either the amount of the fee or nonpayment
of bills for compensable medical services, notwithstanding any other provision
of this chapter, the injured worker, insurer, self-insured employer or medical
service provider may request administrative review by the director. The
decision of the director is subject to review under ORS 656.704.
(13) The director
may exclude hospitals defined in ORS 442.470 from imposition of a fee schedule
authorized by this section upon a determination of economic necessity. [Amended
by 1965 c.285 §26; 1969 c.611 §1; 1971 c.329 §1; 1981 c.535 §5; 1983 c.816 §6;
1985 c.107 §1; 1985 c.739 §5; 1987 c.884 §42; 1990 c.2 §14; 1995 c.332 §26;
1999 c.233 §1; 2005 c.26 §6; 2009 c.36 §2]
Notes of Decisions
State Accident Ins. Fund v. Anderson, 894 P.2d 1152 (Or. 1995).
· cites it 36× “085 * * * as follows: “* * * Pursuant to ORS 656.248, defendant ANDERSON was required to charge no more to SAIF for services rendered than that which was charged to the general public.”
State v. Workman, 455 P.3d 566 (Or. Ct. App. 2019).
· cites it 2× “By statute, ORS 656.248, the rates contained in Oregon’s workers’ compensation fee schedules “shall represent the reimbursement generally received for the services provided” and must be based on “any one or all of the following” types of information about the medical services…”
Cascade Physical Therapy v. Hartford Cas. Ins., 310 P.3d 1156 (Or. Ct. App. 2013).
· cites it 8× “Cascade asserts that the director’s interpretation of OAR 436-009-0040(1) is not plausible because it is inconsistent with the rule’s text and also “exceeds the [d]irector’s authority under the workers’ compensation statutes and violates the provisions of ORS 656.248.” As…”
Dowell v. Oregon Mut. Ins. Co., 388 P.3d 1050 (Or. 2017).
“That statute states that a healthcare provider cannot charge more than the amount in “fee *76 schedules for medical services” published by the Director of the Department of Consumer and Business Services pursuant to ORS 656.248. 7 We conclude, however, that the presumption and…”
Safeway Stores, Inc. v. Cornell, 939 P.2d 99 (Or. Ct. App. 1997).
· cites it 5× “It does not provide for fees when the claimant prevails in a dispute pursuant to ORS 656.248. Claimant argues that this case involves a dispute pursuant to ORS 656.”
State v. Fox, 496 P.3d 10 (Or. Ct. App. 2021).
“at 625 (citing ORS 656.248(1)). We do not deviate from the analysis in Workman and likewise conclude that Shaw’s testimony in this case was sufficient to estab- lish that the medical expenses paid by CVSD on behalf of J were at or below the market rate and, therefore, reasonable.”
Jordan v. SAIF Corp., 167 P.3d 451 (Or. 2007).
“245 (granting authority over certain medical treatment issues to director); ORS 656.248 (granting authority to director to promulgate rules regarding reimbursement for medical services); ORS 656.”
Schlecht v. State Accident Ins. Fund Corp., 653 P.2d 1284 (Or. Ct. App. 1982).
““(3) For the purpose of determining the respective authority of the director and the board to conduct hearings, investigations and other proceedings under ORS 656.001 to 656.”
State Accident Ins. Fund Corp. v. Anderson, 863 P.2d 509 (Or. Ct. App. 1993).
· cites it 14× “In the light oí Brown, the first issue is whether SAIF’s claim for money had and received derives from ORS 656.248 (3). The parties agree that it does.”
SAIF Corp. v. Reid, 982 P.2d 14 (Or. Ct. App. 1999).
· cites it 2× ““(B) If the insurer or self-insured employer gives notice that the worker is required to receive treatment from the managed care organization, the insurer or self-insured employer must guarantee that any reasonable and necessary services so received * * * will be paid as…”
Haynes v. Weyerhaeuser Co., 706 P.2d 567 (Or. Ct. App. 1985).
· cites it 6× “However, such matters do not include any proceeding under ORS 656.248 or any proceeding resulting therefrom.”
— Or. Rev. Stat. § 656.248(1) — 5 cases
State v. Workman, 455 P.3d 566 (Or. Ct. App. 2019).
“By statute, ORS 656.248, the rates contained in Oregon’s workers’ compensation fee schedules “shall represent the reimbursement generally received for the services provided” and must be based on “any one or all of the following” types of information about the medical services…”
State v. Fox, 496 P.3d 10 (Or. Ct. App. 2021).
“at 625 (citing ORS 656.248(1)). We do not deviate from the analysis in Workman and likewise conclude that Shaw’s testimony in this case was sufficient to estab- lish that the medical expenses paid by CVSD on behalf of J were at or below the market rate and, therefore, reasonable.”
Cascade Physical Therapy v. Hartford Cas. Ins., 310 P.3d 1156 (Or. Ct. App. 2013).
“Cascade asserts that the director’s interpretation of OAR 436-009-0040(1) is not plausible because it is inconsistent with the rule’s text and also “exceeds the [d]irector’s authority under the workers’ compensation statutes and violates the provisions of ORS 656.248.” As…”
— Or. Rev. Stat. § 656.248(11) — 1 case
Cascade Physical Therapy v. Hartford Cas. Ins., 310 P.3d 1156 (Or. Ct. App. 2013).
“Cascade asserts that the director’s interpretation of OAR 436-009-0040(1) is not plausible because it is inconsistent with the rule’s text and also “exceeds the [d]irector’s authority under the workers’ compensation statutes and violates the provisions of ORS 656.248.” As…”
— Or. Rev. Stat. § 656.248(12) — 1 case
— Or. Rev. Stat. § 656.248(13) — 5 cases
State Accident Ins. Fund v. Anderson, 894 P.2d 1152 (Or. 1995).
“085 * * * as follows: “* * * Pursuant to ORS 656.248, defendant ANDERSON was required to charge no more to SAIF for services rendered than that which was charged to the general public.”
Safeway Stores, Inc. v. Cornell, 939 P.2d 99 (Or. Ct. App. 1997).
“It does not provide for fees when the claimant prevails in a dispute pursuant to ORS 656.248. Claimant argues that this case involves a dispute pursuant to ORS 656.”
State Accident Ins. Fund Corp. v. Anderson, 863 P.2d 509 (Or. Ct. App. 1993).
“In the light oí Brown, the first issue is whether SAIF’s claim for money had and received derives from ORS 656.248 (3). The parties agree that it does.”
— Or. Rev. Stat. § 656.248(2) — 3 cases
Cascade Physical Therapy v. Hartford Cas. Ins., 310 P.3d 1156 (Or. Ct. App. 2013).
“Cascade asserts that the director’s interpretation of OAR 436-009-0040(1) is not plausible because it is inconsistent with the rule’s text and also “exceeds the [d]irector’s authority under the workers’ compensation statutes and violates the provisions of ORS 656.248.” As…”
Haynes v. Weyerhaeuser Co., 706 P.2d 567 (Or. Ct. App. 1985).
“However, such matters do not include any proceeding under ORS 656.248 or any proceeding resulting therefrom.”
— Or. Rev. Stat. § 656.248(3) — 2 cases
State Accident Ins. Fund v. Anderson, 894 P.2d 1152 (Or. 1995).
“085 * * * as follows: “* * * Pursuant to ORS 656.248, defendant ANDERSON was required to charge no more to SAIF for services rendered than that which was charged to the general public.”
State Accident Ins. Fund Corp. v. Anderson, 863 P.2d 509 (Or. Ct. App. 1993).
“In the light oí Brown, the first issue is whether SAIF’s claim for money had and received derives from ORS 656.248 (3). The parties agree that it does.”
— Or. Rev. Stat. § 656.248(4) — 2 cases
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