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| Volume 7/Winter 2007 Qviews is a quarterly newsletter containing important product updates, company news and information relevant to medical bill payors in the workers' compensation industry. |
Qmedtrix looks ahead to
new year, new services |
| This past year, Qmedtrix
completed a significant system enhancement to more effectively apply
validation and edit rules separately from the BillChek database rate.
Three new service states – Illinois, Kentucky and South Carolina
– were also added last year after extensive analysis indicated
defendable reviews can be provided in those jurisdictions.
This year promises to be even more exciting. Qmedtrix is currently developing new services to complement the BillChek specialty bill review service. Stay tuned for further developments! Texas ruling affects IPH stop-loss bills The State of Office of Administrative Hearings (SOAH) in Texas handed down a en banc decision, which attempted to clarify an earlier contradictory decision regarding interpretation of the stop-loss provision referenced in 28 TAC § 134.401. SOAH ruled that the only factor determining whether the stop-loss provision has been triggered is whether hospital’s total billed charges exceed $40,000. All other considerations are excluded. Historically, the Division and payors have successfully argued that unusually extensive or costly inpatient hospital stays, not just the billed amount, should be considered in triggering stop-loss. The notion of unusually extensive or costly originated via a staff report drafted by Allen C. McDonald, Jr, then acting Director of the Medical Review Division of the TWCC, in an attempt to clarify the stop-loss provision. The Travis County District Court would preside over any appeal over the en banc decision, as SOAH no longer hears appeals relating to Department of Insurance decisions in medical fee disputes. Qmedtrix will continue to process Texas stop-loss hospital bills. This ruling by SOAH will not affect fee disputes until after an appellate decision from the Travis County District Court. Delaware legislature proposes medical fee payment level Last month, the governor of Delaware signed into effect workers’ compensation reform measures, including the creation a 19-member panel to develop inpatient and outpatient fee schedules. The newly created panel will base medical fee payment levels at the 85th percentile range of usual and customary charges. The data used to determine the 85th percentile will come from medical service charges after October 31, 2006. No timeframes released regarding the development of the actual fee schedules. The new reforms also include a provision, which effective immediately, prohibits the balance billing of the employee or employer. Qmedtrix will continue to negotiate bills in Delaware, and will advise you of any additional BillChek service changes after the fee schedule release. 
For more information, questions or comments, visit our web site or contact Joanie Tardie at jtardie@qmedtrix.com
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