HOME » No Fee Schedule on Arizona Workers’ Compensation Claim Case Study

Issues

Answers

Outcomes

At time of placement, no payment had been processed on the claim. In the course of pursuing this matter with the carrier, Convergent confirmed that the claim was under Arizona jurisdiction. Unlike Nevada, the State of Arizona does not have a workers’ compensation fee schedule that establishes specific payment rates for workers’ compensation claims.

Instead, the Arizona rules provide that claims are to be paid based on the hospital’s usual and customary charges. In practice, many carriers seek to contend that payment should be sharply limited despite this, with reference to the per diem amount available under the Nevada fee schedule (since the hospital “customarily” accepts this on in-state claims, though this obviously occurs as a matter of law), or with reference to Medicare cost data, such as Medicare cost-to-charge ratios. In this case, Convergent engaged with the carrier’s agent to negotiate the amount that would be paid pursuant to the Arizona rules.

As a result, on a claim with total charges in excess of $224,000.00, Convergent succeeded in negotiating a final settlement in the amount of $199,585.55, a full 90% of the total charge amount. Convergent worked with the carrier to process this full settlement amount and deliver it to the hospital within ten days of Convergent’s first settlement discussions with the carrier.