Which Medical Fee Schedule Applies in Georgia and Surrounding States?

There are several instances when a Georgia workers’ compensation claimant may receive authorized medical treatment from an out-of-state provider in non-emergency scenarios.  For example, an authorized treating physician may make a referral to a specialist in another state, which is not uncommon in metro areas near the state line.  It is also possible an out-of-state provider may be on a panel, or it could be the case where a claimant has moved outside of Georgia for a legitimate reason.  In any event, the question arises whether the treating provider is entitled to reimbursement under the Georgia Workers’ Compensation Fee Schedule or the fee schedule of their home state.

Under the “General Reimbursement Requirements” of the Georgia fee schedule, the applicable fee schedule will be determined by which state has jurisdiction over the workers’ compensation claim.  With that said, we note there is nothing in the Georgia fee schedule that prohibits an out-of-state provider from setting its own rates when treating Georgia claimants.  As such, an employer/insurer would be well-advised to negotiate a written agreement with an out-of-state provider regarding reimbursement prior to provision of medical services.  This cannot be arranged in all scenarios, but as a practical matter, providers near the Georgia state line should have an interest in working with Georgia employers/insurers both to maintain a good working relationship and to avoid repetitive fee disputes with Georgia employers/insurers.

We also note that the states surrounding Georgia are typically broader in their application of their own fee schedules for claims they have jurisdiction over.  This could be an issue when an out-of-state claimant seeks to treat in Georgia.

• North Carolina: Out-of-state providers are allowed to build charges in full or based on a prior agreement is one has been established.  However, if one has not been established, providers are advised to expect reimbursements under their own state’s fee schedule.

• South Carolina: The fee schedule explicitly excludes services provided outside of South Carolina from their fee schedule.  Furthermore, the South Carolina Supreme Court has found that the South Carolina Workers’ Compensation Commission does not have jurisdiction over a fee dispute relating to fees charged by an out-of-state medical provider or services performed outside of South Carolina, even relating to an injury occurring in South Carolina.

• Florida: Prior authorization is required for non-emergency medical treatment, including out-of-state providers.  As such, out-of-state providers treating Florida claimants have an incentive to pre-arrange reimbursement amounts.  If there is no reimbursement agreement in place, the Florida rules indicate that the reimbursement amount shall be the greater of the Florida fee schedule or the fee schedule for the out-of-state provider’s state.

• Alabama: The rules specifically indicate that the Alabama fee schedule is premised upon treatment being provided in Alabama for Alabama claimants.  However, the rules provide that out-of-state medical treatment for Alabama claimants shall be reimbursed upon the rate of the out-of-state providers fee schedule, pursuant to a mutually negotiated agreement between the provider and the employer/insurer or pursuant to the Alabama fee schedule for non-facility medical providers.

• Tennessee: Their fee schedule only applies to claimants seeking benefits under Tennessee law.  However, under their rules, the fee schedule applies in any state where the Tennessee claimant seeks medical treatment.

Ultimately, the trend among Georgia and the bordering states is for employers/insurers and medical providers to negotiate reimbursement terms upfront to limit disputes and delays in claimants receiving treatment or providers receiving reimbursement.  Doing so can help all parties avoid out-of-state legal proceedings regarding medical bills for workers’ compensation claimants.