Okla. Stat. tit. 85A, § 85A-50

- Fee schedule - Formulary.

A. The employer shall promptly provide an injured employee with

medical, surgical, hospital, optometric, podiatric, chiropractic and

nursing services, along with any medicine, crutches, ambulatory

devices, artificial limbs, eyeglasses, contact lenses, hearing aids,

and other apparatus as may be reasonably necessary in connection

with the injury received by the employee. The employer shall have

the right to choose the treating physician or chiropractor.

B. If the employer fails or neglects to provide medical

treatment within five (5) days after actual knowledge is received of

an injury, the injured employee may select a physician or

chiropractor to provide medical treatment at the expense of the

employer; provided, however, that the injured employee, or another

in the employee's behalf, may obtain emergency treatment at the

expense of the employer where such emergency treatment is not

provided by the employer.

C. Diagnostic tests shall not be repeated sooner than six (6)

months from the date of the test unless agreed to by the parties or

ordered by the Commission for good cause shown.

Oklahoma Statutes - Title 85A. Workers' Compensation Page 81

D. Unless recommended by the treating doctor or chiropractor at

the time claimant reaches maximum medical improvement or by an

independent medical examiner, continuing medical maintenance shall

not be awarded by the Commission. The employer or insurance carrier

shall not be responsible for continuing medical maintenance or pain

management treatment that is outside the parameters established by

the Physician Advisory Committee or ODG. The employer or insurance

carrier shall not be responsible for continuing medical maintenance

or pain management treatment not previously ordered by the

Commission or approved in advance by the employer or insurance

carrier.

E. An employee claiming or entitled to benefits under the

Administrative Workers' Compensation Act, shall, if ordered by the

Commission or requested by the employer or insurance carrier, submit

himself or herself for medical examination. If an employee refuses

to submit himself or herself to examination, his or her right to

prosecute any proceeding under the Administrative Workers'

Compensation Act shall be suspended, and no compensation shall be

payable for the period of such refusal.

F. For compensable injuries resulting in the use of a medical

device, ongoing service for the medical device shall be provided in

situations including, but not limited to, medical device battery

replacement, ongoing medication refills related to the medical

device, medical device repair, or medical device replacement.

G. The employer shall reimburse the employee for the actual

mileage in excess of twenty (20) miles round trip to and from the

employee's home to the location of a medical service provider for

all reasonable and necessary treatment, for an evaluation of an

independent medical examiner and for any evaluation made at the

request of the employer or insurance carrier. The rate of

reimbursement for such travel expense shall be the official

reimbursement rate as established by the State Travel Reimbursement

Act. In no event shall the reimbursement of travel for medical

treatment or evaluation exceed six hundred (600) miles round trip.

H. Fee Schedule.

1. The Commission shall conduct a review and update of the

Current Procedural Terminology (CPT) in the Fee Schedule every two
rsement for such travel expense shall be the official

reimbursement rate as established by the State Travel Reimbursement

Act. In no event shall the reimbursement of travel for medical

treatment or evaluation exceed six hundred (600) miles round trip.

H. Fee Schedule.

1. The Commission shall conduct a review and update of the

Current Procedural Terminology (CPT) in the Fee Schedule every two

(2) years pursuant to the provisions of paragraph 14 of this

subsection. The Fee Schedule shall establish the maximum rates that

medical providers shall be reimbursed for medical care provided to

injured employees including, but not limited to, charges by

physicians, chiropractors, dentists, counselors, hospitals,

ambulatory and outpatient facilities, clinical laboratory services,

diagnostic testing services, and ambulance services, and charges for

durable medical equipment, prosthetics, orthotics, and supplies.

The most current Fee Schedule established by the Administrator of

the Workers' Compensation Court prior to February 1, 2014, shall

Oklahoma Statutes - Title 85A. Workers' Compensation Page 82

remain in effect, unless or until the Legislature approves the

Commission's proposed Fee Schedule.

2. Reimbursement for medical care shall be prescribed and

limited by the Fee Schedule. The director of the Employees Group

Insurance Division of the Office of Management and Enterprise

Services shall provide the Commission such information as may be

relevant for the development of the Fee Schedule. The Commission

shall develop the Fee Schedule in a manner in which quality of

medical care is assured and maintained for injured employees. The

Commission shall give due consideration to additional requirements

for physicians treating an injured worker under the Administrative

Workers' Compensation Act, including, but not limited to,

communication with claims representatives, case managers, attorneys,

and representatives of employers, and the additional time required

to complete forms for the Commission, insurance carriers, and

employers.

3. In making adjustments to the Fee Schedule, the Commission

shall use, as a benchmark, the reimbursement rate for each Current

Procedural Terminology (CPT) code provided for in the fee schedule

published by the Centers for Medicare and Medicaid Services of the

U.S. Department of Health and Human Services for use in Oklahoma

(Medicare Fee Schedule) on the effective date of this section,

workers' compensation fee schedules employed by neighboring states,

the latest edition of "Relative Values for Physicians" (RVP), usual,

customary and reasonable medical payments to workers' compensation

health care providers in the same trade area for comparable

treatment of a person with similar injuries, and all other data the

Commission deems relevant. For services not valued by CMS, the

Commission shall establish values based on the usual, customary and

reasonable medical payments to health care providers in the same

trade area for comparable treatment of a person with similar

injuries.

a. No reimbursement shall be allowed for any magnetic

resonance imaging (MRI) unless the MRI is provided by

an entity that meets Medicare requirements for the

payment of MRI services or is accredited by the

American College of Radiology, the Intersocietal

Accreditation Commission or the Joint Commission on

Accreditation of Healthcare Organizations. For all

other radiology procedures, the reimbursement rate

shall be the lesser of the reimbursement rate allowed

by the 2010 Oklahoma Fee Schedule and two hundred

seven percent (207%) of the Medicare Fee Schedule.

b. For reimbursement of medical services for Evaluation

and Management of injured employees as defined in the

Fee Schedule adopted by the Commission, the

Oklahoma Statutes - Title 85A. Workers' Compensation Page 83

reimbursement rate shall not be less than one hundred

fifty percent (150%) of the Medicare Fee Schedule.
hedule and two hundred

seven percent (207%) of the Medicare Fee Schedule.

b. For reimbursement of medical services for Evaluation

and Management of injured employees as defined in the

Fee Schedule adopted by the Commission, the

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reimbursement rate shall not be less than one hundred

fifty percent (150%) of the Medicare Fee Schedule.

c. Any entity providing durable medical equipment,

prosthetics, orthotics or supplies shall be accredited

by a CMS-approved accreditation organization. If a

physician provides durable medical equipment,

prosthetics, orthotics, prescription drugs, or

supplies to a patient ancillary to the patient's

visit, reimbursement shall be no more than ten percent

(10%) above cost.

d. The Commission shall develop a reasonable stop-loss

provision of the Fee Schedule to provide for adequate

reimbursement for treatment for major burns, severe

head and neurological injuries, multiple system

injuries, and other catastrophic injuries requiring

extended periods of intensive care. An employer or

insurance carrier shall have the right to audit the

charges and question the reasonableness and necessity

of medical treatment contained in a bill for treatment

covered by the stop-loss provision.

4. The right to recover charges for every type of medical care

for injuries arising out of and in the course of covered employment

as defined in the Administrative Workers' Compensation Act shall lie

solely with the Commission. When a medical care provider has

brought a claim to the Commission to obtain payment for services, a

party who prevails in full on the claim shall be entitled to

reasonable attorney fees.

5. Nothing in this section shall prevent an employer, insurance

carrier, group self-insurance association, or certified workplace

medical plan from contracting with a provider of medical care for a

reimbursement rate that is greater than or less than limits

established by the Fee Schedule.

6. A treating physician may not charge more than Four Hundred

Dollars ($400.00) per hour for preparation for or testimony at a

deposition or appearance before the Commission in connection with a

claim covered by the Administrative Workers' Compensation Act.

7. The Commission's review of medical and treatment charges

pursuant to this section shall be conducted pursuant to the Fee

Schedule in existence at the time the medical care or treatment was

provided. The judgment approving the medical and treatment charges

pursuant to this section shall be enforceable by the Commission in

the same manner as provided in the Administrative Workers'

Compensation Act for the enforcement of other compensation payments.

8. Charges for prescription drugs dispensed by a pharmacy shall

be limited to ninety percent (90%) of the average wholesale price of

the prescription, plus a dispensing fee of Five Dollars ($5.00) per

prescription. "Average wholesale price" means the amount determined

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from the latest publication designated by the Commission.

Physicians shall prescribe and pharmacies shall dispense generic

equivalent drugs when available. If the National Drug Code, or

"NDC", for the drug product dispensed is for a repackaged drug, then

the maximum reimbursement shall be the lesser of the original

labeler's NDC and the lowest-cost therapeutic equivalent drug

product. Compounded medications shall be billed by the compounding

pharmacy at the ingredient level, with each ingredient identified

using the applicable NDC of the drug product, and the corresponding

quantity. Ingredients with no NDC area are not separately

reimbursable. Payment shall be based on a sum of the allowable fee

for each ingredient plus a dispensing fee of Five Dollars ($5.00)

per prescription.

9. When medical care includes prescription drugs dispensed by a
the ingredient level, with each ingredient identified

using the applicable NDC of the drug product, and the corresponding

quantity. Ingredients with no NDC area are not separately

reimbursable. Payment shall be based on a sum of the allowable fee

for each ingredient plus a dispensing fee of Five Dollars ($5.00)

per prescription.

9. When medical care includes prescription drugs dispensed by a

physician or other medical care provider and the NDC for the drug

product dispensed is for a repackaged drug, then the maximum

reimbursement shall be the lesser of the original labeler's NDC and

the lowest-cost therapeutic equivalent drug product. Payment shall

be based upon a sum of the allowable fee for each ingredient plus a

dispensing fee of Five Dollars ($5.00) per prescription. Compounded

medications shall be billed by the compounding pharmacy.

10. Implantables are paid in addition to procedural

reimbursement paid for medical or surgical services. A

manufacturer's invoice for the actual cost to a physician, hospital

or other entity of an implantable device shall be adjusted by the

physician, hospital or other entity to reflect, at the time

implanted, all applicable discounts, rebates, considerations and

product replacement programs and shall be provided to the payer by

the physician or hospital as a condition of payment for the

implantable device. If the physician, or an entity in which the

physician has a financial interest other than an ownership interest

of less than five percent (5%) in a publically traded company,

provides implantable devices, this relationship shall be disclosed

to patient, employer, insurance company, third-party commission,

certified workplace medical plan, case managers, and attorneys

representing claimant and defendant. If the physician, or an entity

in which the physician has a financial interest other than an

ownership interest of less than five percent (5%) in a publicly

traded company, buys and resells implantable devices to a hospital

or another physician, the markup shall be limited to ten percent

(10%) above cost.

11. Payment for medical care as required by the Administrative

Workers' Compensation Act shall be due within forty-five (45) days

of the receipt by the employer or insurance carrier of a complete

and accurate invoice, unless the employer or insurance carrier has a

good-faith reason to request additional information about such

invoice. Thereafter, the Commission may assess a penalty up to

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twenty-five percent (25%) for any amount due under the Fee Schedule

that remains unpaid on the finding by the Commission that no good-

faith reason existed for the delay in payment. If the Commission

finds a pattern of an employer or insurance carrier willfully and

knowingly delaying payments for medical care, the Commission may

assess a civil penalty of not more than Five Thousand Dollars

($5,000.00) per occurrence.

12. If an employee fails to appear for a scheduled appointment

with a physician or chiropractor, the employer or insurance company

shall pay to the physician or chiropractor a reasonable charge, to

be determined by the Commission, for the missed appointment. In the

absence of a good-faith reason for missing the appointment, the

Commission shall order the employee to reimburse the employer or

insurance company for the charge.

13. Physicians or chiropractors providing treatment under the

Administrative Workers' Compensation Act shall disclose under

penalty of perjury to the Commission, on a form prescribed by the

Commission, any ownership or interest in any health care facility,

business, or diagnostic center that is not the physician's or

chiropractor's primary place of business. The disclosure shall

include any employee leasing arrangement between the physician or

chiropractor and any health care facility that is not the
sclose under

penalty of perjury to the Commission, on a form prescribed by the

Commission, any ownership or interest in any health care facility,

business, or diagnostic center that is not the physician's or

chiropractor's primary place of business. The disclosure shall

include any employee leasing arrangement between the physician or

chiropractor and any health care facility that is not the

physician's or chiropractor's primary place of business. A

physician's or chiropractor's failure to disclose as required by

this section shall be grounds for the Commission to disqualify the

physician or chiropractor from providing treatment under the

Administrative Workers' Compensation Act.

14. a. Beginning on May 28, 2019, the Commission shall

conduct an evaluation of the Fee Schedule, which shall

include an update of the list of Current Procedural

Terminology (CPT) codes, a line item adjustment or

renewal of all rates, and amendment as needed to the

rules applicable to the Fee Schedule.

b. The Commission shall contract with an external

consultant with knowledge of workers' compensation fee

schedules to review regional and nationwide

comparisons of Oklahoma's Fee Schedule rates and date

and market for medical services. The consultant shall

receive written and oral comment from employers,

workers' compensation medical service and insurance

providers, self-insureds, group self-insurance

associations of this state and the public. The

consultant shall submit a report of its findings and a

proposed amended Fee Schedule to the Commission.

c. The Commission shall adopt the proposed amended Fee

Schedule in whole or in part and make any additional

updates or adjustments. The Commission shall submit a

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proposed updated and adjusted Fee Schedule to the

President Pro Tempore of the Senate, the Speaker of

the House of Representatives and the Governor. The

proposed Fee Schedule shall become effective on July 1

following the legislative session, if approved by

Joint Resolution of the Legislature during the session

in which a proposed Fee Schedule is submitted.

d. Beginning on May 28, 2019, an external evaluation

shall be conducted and a proposed amended Fee Schedule

shall be submitted to the Legislature for approval

during the 2020 legislative session. Thereafter, an

external evaluation shall be conducted and a proposed

amended Fee Schedule shall be submitted to the

Legislature for approval every two (2) years.

I. Formulary. The Commission by rule shall adopt a closed

formulary. Rules adopted by the Commission shall allow an appeals

process for claims in which a treating doctor determines and

documents that a drug not included in the formulary is necessary to

treat an injured employee's compensable injury. The Commission by

rule shall require the use of generic pharmaceutical medications and

clinically appropriate over-the-counter alternatives to prescription

medications unless otherwise specified by the prescribing doctor, in

accordance with applicable state law.