Qviews

Volume 4/ Spring 2006

Qviews is a quarterly newsletter containing important product updates, company news and information relevant to medical bill payors in the workers' compensation industry.

Texas DWC Validates Qmedtrix Methodology

During the past two months, the Texas Division of Workers Compensation (DWC) has ruled on nine cases involving a Qmedtrix review. In each case, the DWC upheld that Qmedtrix' recommended reimbursement was in line with the "fair and reasonable" rate as directed by Commission Rule 134.1.

Additionally, the commission found the Qmedtrix recommended reimbursement to be within the reimbursement rate recommended by the Ingenix study (from 213.3% to 290% of Medicare), which was the basis of the Texas ambulatory surgery center (ASC) fee schedule. The DWC is applying the fee schedule retroactively to disputed ASC cases with dates of service before the September 1, 2004.

The DWC is sending the same message that Qmedtrix has championed for years – fair reimbursement to providers. Regardless of the jurisdiction, Qmedtrix's methodology provides for unequivocal evidence in support of a "fair and reasonable" reimbursement level. This methodology is particularly strong in Texas because it ties directly with the spirit and the language of the commission's rules.

Qmedtrix offers new services in Illinois

Qmedtrix announced new service changes in Illinois after the state enacted a fee schedule, which took effect February 1, 2006. The new service will include identifying billing errors using outpatient code editor (OCE) edits and Current Procedural Terminology (CPT) code edits associated with the National Correct Coding Initiative (NCCI). Qmedtrix will also scrutinize non pass-through charges to spot incorrectly coded charges that should be paid as "pass through charges" at the lower rate of reimbursement.

Qmedtrix's DRG Validation service will apply in Illinois for charges falling under the new two-tier DRG-based inpatient hospital fee schedule. Cost-outlier verification is included for charges that exceed the threshold.

The change is the first step in a calculated approach to align services in Illinois with similar services Qmedtrix offers in other states where fee schedule amounts are based on a percentage of charges.