Workers Compensation Medical Fee Schedule Study Services

The vendor is required to provide workers compensation medical fee schedule study services for include:
- Benchmarking analysis
•    Conduct a comparative, frequency-weighted benchmarking analysis using the following data sources:
o    Medicare rates
o    Paid, allowed, and billed amounts from state workers’ compensation claims
o    Group health data, if available
•    Clearly define “paid,” “allowed,” and “billed” within the methodology
•    Disclose all data sources, sample sizes, and explain data interpretation methods
•    Provide benchmarking across all CPT code ranges:
o    Anesthesia (00000–99999)
o    Surgery (10000–69999)
o    Radiology (70000–79999)
o    Pathology and laboratory (80000–89999)
o    Medicine and e/m (90000–99999)
•    Identify and justify the top 100 cost driver codes, including selection methodology 
•    Ensure recommended fees:
o    Exceed usual and customary billed and paid amounts in state
o    Are not unfairly discriminatory among legally qualified providers
- Conversion factor recommendations
•    Using the resource-based relative value scale (RBRVS) and national benchmarks, the vendor shall recommend updated conversion factors for:
o    Anesthesia
o    Surgery
o    Radiology
o    Pathology and laboratory
o    General medicine
o    E/M
•    Base recommendations on a cost impact analysis comparing:
•    Current 2025 state medical fee schedule (MFS) rates:
o    Anesthesia: $99.01
o    Surgery: $283.69
o    Radiology: $51.37
o    Pathology: $30.48
o    General medicine: $13.31
•    Medicare and national benchmarks
o    Recommend a cpi-based update using the cpi medical care component, per nrs 616c.260(2). 
o    Align with the most current editions of the relative values for physicians and the relative value guide of the american society of anesthesiologists
- Relative value units (RVUs)
•    Recommend RVUs for services or codes not currently represented in the RBRVS or MFS
- Hospital and inpatient services
•    Review and recommend maximum allowable payments for inpatient care, including:
o    Medical-surgical: $3,733.97
o    ICU: $6,139.88
o    Step-down: $4,936.92
o    Skilled nursing: $2,559.01
o    Observation (>23 hrs.): $3,733.97
o    observation (≤23 hrs.): $155.58 and HR 
o    psychiatric and rehab: $2,559.01
o    rehabilitation: $2,559.01
•    Clarify bundled services and professional vs. facility billing distinctions
- Dental services
•    Review and recommend maximum allowable payments for dental using codes (e.g., d0120 to d9223). for unlisted codes, establish usual and customary pricing benchmarks.
- Ambulatory surgery centers (ASC)
•    Using the ASC hospital outpatient group list 2016, recommend reimbursement rates for surgical codes grouped 1-9, as currently reimbursed under the 2025 MFS
•    Address unlisted CPT codes reimbursed at $3,468.99 and provide methodology for rate assignment.
- Bundling and global service editing
•    Evaluate the feasibility of adopting nationally recognized bundling edits and global periods, and recommend adoption, modification, or continued exclusion based on impact and practicality. 
- Miscellaneous services
•    Recommend maximum allowable payments for the following: 
- Telemedicine
•    Telemedicine services as defined by services provided to an injured employee at an originating site, rural healthcare facility by a consulting physician or chiropractor located at a distant site in another rural healthcare facility or in an urban healthcare facility and medical information is communicated between the injured employee and consulting physician or chiropractor in real-time with the use of simultaneous interactive audio and video communication equipment.
•    Originating site fee (nv00250): $266.37
•    Services to be billed with GT modifier, using standard CPT codes
- Emergency department facility fees 
•    First hour (nv00100): $311.18
•    Each additional hour (nv00101): $155.58
•    Trauma activation fee (nv00150): $4,486.82
- Ambulance services
•    Include ground and air ambulance transportation rates
- Pharmaceuticals
•    Average wholesale price + $13.31 dispensing fee or usual and customary (U&C), whichever is lower
•    Compound medications must list all ingredients with valid national drug codes (NDCS)
•    Prior authorization required for compound prescriptions
- Drug and alcohol testing
•    Appropriate CPT codes and reimbursement rates
- Home health care
•    Skilled care (per visit, nv90170): $148.52
•    CNA care (per visit, nv90130): $72.37
•    Hourly rates: skilled $74.24; CNA $36.19
- Durable medical equipment (DME), including custom DME 
•    Reimbursed at actual cost + 20% markup with invoice
- Custom orthotics and prosthetics 
•    Reimbursed at 140% of medicare allowable for state
- Permanent partial disability (PPD) evaluations
•    Review records, testing, evaluation, and report (includes evaluation of up to two body parts) (nv01000): $980.57
•    Review of medical records and evaluation of each additional body part in excess of initial two body parts (nv01004): $327.49
•    Organization of medical records in chronological order based on the date of service per 50 pages (nv01005) $55.23
•    Failure of an injured employee to appear for appointment (nv01001): $327.49
•    Review of records and report (nv01006) $489.31
- Independent medical evaluations (IMES)
•    Review of medical records (up to 50 pages) (nv02001): $2,022.43
•    Review of each additional 100 pages of medical records (nv02002): $505.61
•    Evaluation of each additional body part in excess of initial two body parts (nv02003): $379.21
•    Organization of medical records in chronological order based on date of service per 50 pages (nv02004): $55.23
•    Failure of an injured employee to appear for appointment (nv02000): $758.40
- Functional capacity evaluations (FCES)
•    Evaluation (nv99060): $308.43 and HR 
•    No-show (nv99061): $327.49
- Work hardening programs
•    Propose methodology and rate structure
- Back school (nv97115)
•    Reimbursed at $108.55 and HR 
- Consultation services
•    Provide up to 15 hours of virtual consultation with DIR for clarification and interpretation of deliverables 
•    Provide up to 6 hours of in-person consultation with DIR upon request.
- Statutory and regulatory compliance 
•    Ensure all recommendations comply with NRS 616c.260 and meet the following criteria:
o    Reflect state -specific billing trends
o    Align with ama CPT coding standards
o    Avoid discrimination among qualified providers
o    Include documentation and interpretation support for DIR
o    Propose compliance monitoring methods 
o    Support competitive bidding and vendor designation
o    Present findings in a format suitable for annual schedule updates 
o    Recommend appropriate frequency for comprehensive fee schedule reviews.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: September 29, 2025