Delaware Code Title 19. Labor § 2322F. Billing and payment for health-care services

(a) Charges for medical evaluation, treatment and therapy, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice for such charges, accompanied by records or notes, concerning the treatment or services submitted for payment, documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy, with reference to the health care practice guidelines adopted pursuant to § 2322C of this title, or documenting the preauthorization of such evaluation, treatment or therapy.  The initial copy of the supporting notes or records shall be produced without separate or additional charge to the employer, insurance carrier or employee.

(b) Charges for hospital services and items supplied by a hospital, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice which shall be documented in a nationally recognized uniform billing code format, in sufficient detail to document the services or items provided, and any preauthorization of the services and items shall also be documented.  The initial copy of the supporting medical notes or records shall be produced without separate or additional charge to the employer, insurance carrier or employee.  Payment for hospital services, including payment for invoices rendered for emergency department services, shall be made within 30 days of the submission of a “clean claim” accompanied by notes documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy.

(c) Preauthorized evaluations, treatments or therapy shall be paid at the agreed fee within 30 days of the date of submission of the invoice, unless the compliance with the preauthorization is contested, in good faith, pursuant to the utilization review system set forth in subsection (j) of this section below.

(d) Treatments, evaluations and therapy provided by a certified health care provider shall be paid within 30 days of receipt of the health care provider's bill or invoice together with records or notes as provided in this section, unless compliance with the health care payment system or practice guidelines adopted pursuant to § 2322B or § 2322C of this title is contested, in good faith, to the utilization review system set forth in subsection (j) of this section below.

(e) Denial of payment for health care services provided pursuant to this chapter, whether in whole or in part, shall be accompanied with written explanation of reason for denial.

(f) In the event that a portion of a health care invoice is contested pursuant to this section, the uncontested portion shall be paid without prejudice to the right to contest the remainder.  The time limits set forth in this section shall apply to payment of all uncontested portions of health care payments.

(g) If, following a hearing, the Industrial Accident Board determines that an employer, an insurance carrier or a health care provider failed in its responsibilities under § 2322B , § 2322C , § 2322D , § 2322E or § 2322F of this title, it shall assess a fine of not less than $1,000 nor more than $5,000 for violations of said sections.  Such fines shall be payable to the Workers' Compensation Fund.

(h) Prompt pay required for nonpreauthorized care. --An employer or insurance carrier shall be required to pay a health care invoice within 30 days of receipt of the invoice as long as the claim contains substantially all the required data elements necessary to adjudicate the invoice, unless the invoice is contested in good faith.  If the contested invoice pertains to an acknowledged compensable claim and the denial is based upon compliance with the health care payment system and/or health care practice guidelines, it shall be referred to utilization review.  Any such referral to utilization review shall be made within 15 days of denial.  Unpaid invoices shall incur interest at a rate of 1% per month payable to the provider.  A provider shall not hold an employee liable for costs related to nondisputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

(i) A health care provider referring an employee to, or encouraging an employee to utilize, any inpatient or outpatient facility or any medical or therapeutic practice, laboratory, diagnostic testing or radiological imaging machinery, equipment, practice or facility shall disclose to the employee any financial interest the health care provider has in such inpatient or outpatient facility, any medical or therapeutic practice, laboratory, diagnostic testing or radiological imaging machinery, equipment, practice or facility.  The requirements of this subsection may be met by the prominent placement of a sign or signs in such health care provider's office identifying such affiliated equipment, practices or facilities.

(j) Utilization review. --The Workers’ Compensation Oversight Panel shall approve, propose and maintain a utilization review program for any health-care provider providing services to injured workers pursuant to this chapter whether the provider is or is not certified under § 2322D of this title.  The intent is to provide reference for employers, insurance carriers, and health-care providers for evaluation of health care and charges.  The intended purpose of utilization review services shall be the prompt resolution of issues related to treatment and/or compliance with the health-care payment system or practice guidelines for those claims which have been acknowledged to be compensable.  An employer or insurance carrier may engage in utilization review to evaluate the quality, reasonableness and/or necessity of proposed or provided health-care services for acknowledged compensable claims.  Any person conducting a utilization review program for workers' compensation shall be required to contract with the Office of Workers' Compensation once every 2 years and certify compliance with Workers' Compensation Utilization Management Standards or Health Utilization Management Standards of Utilization Review Accreditation Council (“URAC”) sufficient to achieve URAC accreditation or submit evidence of accreditation by URAC.  If a party disagrees with the findings following utilization review, a petition may be filed with the Industrial Accident Board for de novo review. Complete rules and regulations relating to utilization review shall be approved, proposed and maintained by the Workers’ Compensation Oversight Panel.  Rules recommended by the Panel shall be adopted by regulation of the Department of Labor pursuant to Chapter 101 of Title 29.

(k) Coordination of health care payments.--

(1) Upon notification to an employer that an employee is exercising that employee’s rights under § 2304 of this title with respect to an injury or condition, the employer shall be exclusively responsible for treatment of that injury or condition to the extent that the employer is obliged to provide treatment under this chapter.

(2) An employee, as part of a notification that an employee will exercise rights under § 2304 of this title, shall notify the employer of all health insurance benefits that could compensate the employee for treatment of the injury or condition in question in the absence of coverage under this chapter.  Such notification to the employer is intended to facilitate the notice provided for in paragraph (k)(4) of this section;  the failure of an employee to provide such notice shall not waive or defeat any rights the employee may have under this chapter.

(3) An employee whose health care treatment for an injury or condition is being paid for pursuant to this chapter shall not be entitled to seek compensation from any other health insurance carrier for the same treatment.  A health care provider who is being paid for treating an injury or condition pursuant to this chapter shall not seek compensation from any other health insurance carrier for the same treatment.

(4) At any time that a final determination is made that an employee is not entitled to health care treatment pursuant to this chapter, the employer shall notify any health insurance carrier of which it is aware pursuant to paragraph (k)(2) of this section of such a final determination.

(5) Notwithstanding any other provision of this chapter, if a final determination is made that an employee is not entitled to health care treatment pursuant to this chapter, the employee and/or the health care provider who provided said treatment may seek payment for such treatment from a health insurance carrier from which the employee had coverage applicable at the time of the injury or condition.

(6) Any time restrictions imposed upon an employee with respect to making claims against that employee’s health insurance coverage for an injury or condition for which that employee initially sought treatment under this chapter shall be tolled until notification of the health insurance carrier under paragraph (k)(4) of this section.

(7) No requirements for preauthorization of treatment in any health insurance policy shall be the basis for denying payment of a claim submitted under paragraph (k)(5) of this section.

(8) With respect to claims submitted by an employee pursuant to paragraph (k)(5) of this section for treatment provided by a health care provider that had a contract with the health insurance carrier at the time of the treatment, reimbursement shall be at the contract rate.

(9) With respect to claims submitted by an employee pursuant to paragraph (k)(5) of this section for treatment provided by a health care provider that did not have a contract with the health insurance carrier at the time of the treatment, reimbursement shall be at the health insurance carrier's average contract rate for the same treatment with health care providers with whom it does have a contract.

(10) All claims submitted pursuant to paragraph (k)(5) of this section shall be entitled to treatment under Insurance Department Regulation 1310 [18 Del. Code Regs. § 1310] or any successor regulation relating to the prompt payment of health care claims by health insurance carriers.

(11) A health insurance carrier may deny payment of claims submitted under paragraph (k)(5) of this section for health care that it determines was not reasonable or necessary.  However, an employee shall have the right to immediate appeal to an Independent Utilization Review organization under § 6416 of Title 18 for all such denials of treatment, with the cost of such appeal being borne by the health insurance carrier.

(12) A health care provider may not balance bill an employee for treatment for which the health care provider has been compensated under paragraph (k)(8) or (9) of this section.

(l) Balance billing prohibited.--

(1) Any health care provider rendering services under this chapter shall be prohibited from billing or invoicing an employee, employer or insurance carrier for charges or expenses other than those authorized by this chapter and the health care payment system provided for herein.  No health care provider rendering treatment or services under this chapter shall seek payment for charges from an employee except as authorized by this section.

(2) Billing procedures where compensability under this chapter is contested.

a. A provider may seek payment of the actual charges from the employee if the employer or insurance carrier notifies the provider that it does not consider the illness or injury to be compensable.  If an employer notifies a provider that it will pay only a portion of a bill, the provider may seek payment of the unpaid portion from the employee up to the lesser of the actual charge, the negotiated rate, or the rate authorized by the payment system.

b. If an employee informs the health care provider that a claim is on file at the Department, the provider shall cease all efforts to collect payment from the employee.

c. While a claim concerning compensability is pending with the Department, a provider may notify an employee that the employee will be responsible for payment of unpaid invoices when the claim has been determined not to be compensable and the provider is able to resume collection efforts.  Any such notice or reminder made under this subsection shall not be disclosed or otherwise provided to any credit agency.  The provider may request information about the Department claim, and if the employee fails to respond or provide the information within 90 days, the provider shall be entitled to resume collection efforts directly and the employee may be determined liable for invoices as otherwise provided by law.

(3) Upon final award or settlement, a provider may resume efforts to collect payment from the employee and the employee shall be responsible for payment of any outstanding bills without regard to this section and as otherwise provided or authorized by law.  If the service is found compensable, the provider shall not require a payment rate, excluding interest, greater than the lesser of the actual charge or payment level set by the payment system.  The employee shall be responsible for payment for services found not covered or compensable unless agreed otherwise by the provider and employee.  Services not covered or not compensable shall not be subject to the payment system.


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