{"data":{"id":"us-ky/krs-342.035","jurisdiction":"us-ky","citation":"KRS 342.035","heading":"Administrative regulations -- Medical fee schedule -- Review and updating","body":"-- Action for excess fees -- Effect of failure to submit to or follow surgical or\nmedical treatment or advice -- Certification to commissioner -- Audit --\nUtilization revie w -- Report -- Copies of records -- Practice parameters and\nevidence-based guidelines -- Formulary -- Medical fee schedule for registered\nnurse first assistants.\n(1) Periodically, the commissioner shall promulgate administrative regulations to adopt\na schedule of fees for the purpose of ensuring that all fees, charges, and\nreimbursements under KRS 342.020 and this section shall be fair, current, and\nreasonable and shall be limited to such charges as are fair, current, and reasonable\nfor similar treatm ent of injured persons in the same community for like services,\nwhere treatment is paid for by general health insurers. In determining what fees are\nreasonable, the commissioner may also consider the increased security of payment\nafforded by this chapter. On or before November 1, 1994, and on July 1 every two\n(2) years thereafter, the schedule of fees contained in administrative regulations\npromulgated pursuant to this section shall be reviewed and updated, if appropriate.\nWithin ten (10) days of April 4, 1 994, the commissioner shall execute a contract\nwith an appropriately qualified consultant pursuant to which each of the following\nelements within the workers' compensation system are evaluated; the methods of\nhealth care delivery; quality assurance and uti lization mechanisms; type, frequency,\nand intensity of services; risk management programs; and the schedule of fees\ncontained in administrative regulation. The consultant shall present\nrecommendations based on its review to the commissioner not later than sixty (60)\ndays following execution of the contract. The commissioner shall consider these\nrecommendations and, not later than thirty (30) days after their receipt, promulgate\na regulation which shall be effective on an emergency basis, to effect a twenty -five\npercent (25%) reduction in the total medical costs within the program.\n(2) No provider of medical services or treatment required by this chapter, its agent,\nservant, employee, assignee, employer, or independent contractor acting on behalf\nof any medic al provider, shall knowingly collect, attempt to collect, coerce, or\nattempt to coerce, directly or indirectly, the payment of any charge, for services\ncovered by a workers' compensation insurance plan for the treatment of a work -\nrelated injury or occupati onal disease, in excess of that provided by a schedule of\nfees, or cause the credit of any employee to be impaired by reason of the employee's\nfailure or refusal to pay the excess charge. In addition to the penalty imposed in\nKRS 342.990 for violations of this subsection, any individual who sustains damages\nby any act in violation of the provisions of this subsection shall have a civil cause of\naction in Circuit Court to enjoin further violations and to recover the actual\ndamages sustained by the individual , together with the costs of the lawsuit,\nincluding a reasonable attorney's fee.\n(3) Where these requirements are furnished by a public hospital or other institution,\npayment thereof shall be made to the proper authorities conducting it. No\ncompensation shall be payable for the death or disability of an employee if his or\nher death is caused, or if and insofar as his disability is aggravated, caused, or\ncontinued, by an unreasonable failure to submit to or follow any competent surgical\ntreatment or medical aid or advice.\n(4) The commissioner shall, by December 1, 1994, promulgate administrative\nregulations to adopt a schedule of fees for the purpose of regulating charges by\nmedical providers and other health care professionals for testimony presented and\nmedical reports furnished in the litigation of a claim by an injured employee against\nthe employer. The workers' compensation medical fee schedule for physicians, 803\nKAR 25:089, having an effective date of February 9, 1995, shall remain in effect\nuntil July 1, 1996, or until the effective date of any amendments promulgated by the\ncommissioner, whichever occurs first, it being determined that this administrative\nregulation is within the statutory grant of authority, meets legislative intent, and is\nnot in conf lict with the provisions of this chapter. The medical fee schedule and\namendments shall be fair, current, and reasonable and otherwise comply with this\nsection.\n(5) (a) To ensure compliance with subsections (1) and (4) of this section, the\ncommissioner sha ll promulgate administrative regulations by December 31,\n1994, which require each insurance carrier, self -insured group, and self -\ninsured employer to certify to the commissioner the program or plan it has\nadopted to ensure compliance.\n(b) In addition, the commissioner shall periodically have an independent audit\nconducted by a qualified independent person, firm, company, or other entity\nhired by the commissioner, in accordance with the personal service contract\nprovisions contained in KRS 45A.690 to 45A.725 , to ensure that the\nrequirements of subsection (1) of this section are being met. The independent\nperson, firm, company, or other entity selected by the commissioner to\nconduct the audit shall protect the confidentiality of any information it\nreceives during the audit, shall divulge information received during the audit\nonly to the commissioner, and shall use the information for no other purpose\nthan the audit required by this paragraph.\n(c) The commissioner shall promulgate administrative regulations gove rning\nmedical provider utilization review activities conducted by an insurance\ncarrier, self-insured group, or self -insured employer pursuant to this chapter.\nUtilization review required under administrative regulations may be waived if\nthe insurance carri er, self-insured group, or self -insured employer agrees that\nthe recommended medical treatment is medically necessary and appropriate or\nif the injured employee elects not to proceed with the recommended medical\ntreatment.\n(d) Periodically, or upon request , the commissioner shall report to the Interim\nJoint Committee on Economic Development and Workforce Investment of the\nLegislative Research Commission or to the corresponding standing\ncommittees of the General Assembly, as appropriate, the degree of compliance\nor lack of compliance with the provisions of this section and make\nrecommendations thereon.\n(e) The cost of implementing and carrying out the requirements of this subsection\nshall be paid from funds collected pursuant to KRS 342.122.\n(6) The commissio ner may promulgate administrative regulations incorporating\nmanaged care or other concepts intended to reduce costs or to speed the delivery or\npayment of medical services to employees receiving medical and related benefits\nunder this chapter.\n(7) For purposes of this chapter, any medical provider shall charge only its customary\nfee for photocopying requested documents. However, in no event shall a\nphotocopying fee of a medical provider or photocopying service exceed fifty cents\n($0.50) per page. However, a  medical provider shall not charge a fee when the\ninitial copy of medical records is provided to the injured worker or his or her\nattorney in response to a written request pursuant to KRS 422.317. In addition, there\nshall be no charge for reviewing any rec ords of a medical provider, during regular\nbusiness hours, by any party who is authorized to review the records and who\nrequests a review pursuant to this chapter.\n(8) (a) The commissioner shall develop or adopt practice parameters or evidence -\nbased treatment guidelines for medical treatment for use by medical providers\nunder this chapter, including but not limited to chronic pain management\ntreatment and opioid use, and promulgate administrative regulations in order\nto implement the developed or adopted pr actice parameters or evidenced -\nbased treatment guidelines on or before December 31, 2019. The\ncommissioner may adopt any parameters for medical treatment as developed\nand updated by the federal Agency for Health Care Policy Research, or the\ncommissioner ma y adopt other parameters for medical treatment which are\ndeveloped by qualified bodies, as determined by the commissioner, with\nperiodic updating based on data collected during the application of the\nparameters.\n(b) The commissioner shall develop or adopt a pharmaceutical formulary for\nmedications prescribed for the cure of and relief from the effects of a work\ninjury or occupational disease and promulgate administrative regulations to\nimplement the developed or adopt ed pharmaceutical formulary on or before\nDecember 31, 2018.\n(c) Any provider of medical services under this chapter who has followed the\npractice parameters or treatment guidelines or formularies developed or\nadopted and implemented pursuant to this subsec tion shall be presumed to\nhave met the appropriate legal standard of care in medical malpractice cases\nregardless of any unanticipated complication that may thereafter develop or be\ndiscovered.\n(9) (a) Notwithstanding any other provision of law to the cont rary, the medical fee\nschedule adopted under subsection (4) of this section shall require all worker's\ncompensation insurance carriers, worker's compensation self -insured groups,\nand worker's compensation self -insured employers to provide coverage and\npayment for surgical first assisting services to registered nurse first assistants\nas defined in KRS 216B.015.\n(b) The provisions of this subsection apply only if reimbursement for an assisting\nphysician would be covered and a registered nurse first assistant who\nperformed the services is used as a substitute for the assisting physician. The\nreimbursement shall be made directly to the registered nurse first assistant if\nthe claim is submitted by a registered nurse first assistant who is not an\nemployee of the hospital or the surgeon performing the services.","path":["KRS Chapter 342"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=51281","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:58:30Z","sha256":"19face9c062ce408d200eeb2fe64cd90cbd6f0490843871788e0b508b1d08161","source_id":"us-ky","stale":false,"prev":"us-ky/krs-342.033","next":"us-ky/krs-342.038"},"notice":"GroundRules: Original legal text. Not legal advice."}