Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 52 Pa.B. 7348 (November 26, 2022).

34 Pa. Code § 127.101. Medical fee caps—Medicare.

CALCULATIONS


§ 127.101. Medical fee caps—Medicare.

 (a)  Generally, medical fees for services rendered under the act shall be capped at 113% of the Medicare reimbursement rate applicable in this Commonwealth under the Medicare Program for comparable services rendered. The medical fees allowable under the act shall fluctuate with changes in the applicable Medicare reimbursement rates for services rendered prior to January 1, 1995. Thereafter, for services rendered on and after January 1, 1995, medical fees shall be updated only in accordance with § §  127.151—127.162 (relating to medical fee updates).

 (b)  Medicare coinsurance and deductibles may not be used to reduce the allowable fee under the act.

 (c)  If a provider’s actual charges for services rendered are less than the maximum fee allowable under the act, the provider shall be paid only the actual charges for the services rendered.

 (d)  The Medicare reimbursement mechanisms that shall be used when calculating payments to providers under the act are set forth in § §  127.103—127.128.

 (e)  Medical fee caps based on Medicare will apply to all health care providers licensed in this Commonwealth who treat injured workers, regardless of whether the health care provider participates in the Medicare Program.

 (f)  An insurer may not make payment in excess of the medical fee caps, unless payment is made pursuant to a contract with a CCO certified by the Secretary of Health.

Notes of Decisions

   Third-Party Insurers

   Where claimant’s employer initially denied that her injury was work-related and she proceeded with surgery, which was paid for by her third-party insurer, the third-party insurer was entitled to the full amount paid even if that amount exceeded 113% of the Medicare reimbursement rate. Furnival State Machinery/Transamerica Insurance Group v. Workers’ Compensation Appeal Board (SLYE), 757 A.2d 433 (Pa. Cmwlth. 2000); appeal denied 771 A.2d 1289 (Pa. 2001).



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