A. The director shall adopt and promulgate regulations establishing a schedule of maximum charges as deemed necessary for treatment or attendance, service, devices, apparatus or medicine provided by a health care provider. The rates in the schedules of maximum charges shall not fall below the sixtieth percentile or above the eightieth percentile of current rates for health care providers. In determining current rates for health care providers, the director shall utilize a variety of health care provider charges, including the charges of those providers serving low income, medicare and medicaid patients.
B. A health care provider shall be paid his usual and customary fee for services rendered or the maximum charge established pursuant to Subsection A of this section, whichever is less. However, in no case shall the usual and customary fee exceed the maximum charge allowable.
C. The fee schedule shall be revised annually by the director.
D. No amount in excess of the amount required by Subsection B of this section for a service shall be paid by the employer, the employer's insurer, the worker, a representative of the worker or any other person to a health care provider for rendering that service in connection with an injury or disablement within the purview of the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978].
E. If it is determined by the person primarily responsible for payment that the charges of a health care provider exceed the amount established pursuant to Subsection B of this section or that a health care provider over-utilized or otherwise rendered or ordered inappropriate health care or health care services, and payment is withheld on those grounds, the health care provider may appeal to the director regarding that determination. The director shall establish by regulation procedures for an appeal by a health care provider.
F. The director shall establish an advisory committee that shall:
(1) be appointed and serve at the pleasure of the director;
(2) consist of members, a majority of whom represent health care providers;
(3) reflect the diversity of authorized licensed health care providers available for workers' compensation and occupational disease disablement cases;
(4) assist in establishing the schedules of maximum charges under Subsection A of this section for any fees that are payable to health care providers;
(5) assist the director in adopting regulations for employers' utilization review procedures and the establishment and conduct of utilization review boards; and
(6) report its findings, upon request, to the director and the advisory council on workers' compensation.
G. The schedule of maximum charges specified in this section shall not apply to hospital charges. The director shall establish a separate schedule of maximum charges for hospital charges no later than April 1, 1991.
H. Nothing in this section shall prevent an employer from contracting with a health care provider for fees less than the maximum charges allowable.
History: 1978 Comp., § 52-4-5, enacted by Laws 1990 (2nd S.S.), ch. 2, § 52; 1993, ch. 193, § 9.
ANNOTATIONSThe 1993 amendment, effective June 18, 1993, in Subsection A, substituted the present last sentence for the former last sentence, which read "The regulations adopted under this subsection shall be adopted not later than January 1, 1992, after review, notice and public hearing."; and made a minor stylistic change in Subsection E.
Law reviews. — For survey of 1990-91 workers' compensation law, see 22 N.M.L. Rev. 845 (1992).