Key Differences in Indiana's Fee Schedule
Indiana's workers' compensation medical fee schedule (WCMS) is distinct because it adopts the Medicare fee schedule as its baseline, then applies a state‑specific conversion factor of 1.0 for most services. Unlike some states that use a percentage of Medicare rates, Indiana generally reimburses at 100% of the Medicare allowable, with occasional adjustments for certain procedure categories.
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How the Schedule Is Structured
The schedule groups services into four main categories: physician services, ancillary services, hospital services, and durable medical equipment. Each category references a CPT or HCPCS code, and the corresponding fee is the Medicare amount multiplied by the conversion factor. Updates occur annually, reflecting the Centers for Medicare & Medicaid Services (CMS) updates.
Reimbursement Process for Providers
Providers submit claims using the standard WC‑19 form, listing the CPT/HCPCS code, the number of units, and the fee derived from the schedule. The employer's insurance carrier reviews the claim, verifies that the service is work‑related, and pays the amount shown. If a service is not listed, the provider must request a waiver, supplying supporting documentation for a case‑by‑case determination.
Common Adjustments and Exceptions
While most services follow the 100% rule, Indiana applies the following adjustments:
- Physical therapy and occupational therapy: reimbursed at 80% of the Medicare rate.
- Radiology services: a 95% factor is used for certain imaging procedures.
- Out‑of‑network providers: may be subject to a 90% factor unless a network agreement exists.
Comparative Fee Table
| Service Category | Standard Factor | Typical Adjustment |
|---|---|---|
| Physician office visit (CPT 99213) | 1.00 | None |
| Physical therapy (CPT 97001) | 0.80 | State‑mandated reduction |
| Diagnostic X‑ray (CPT 71020) | 0.95 | Imaging specific |
| Durable medical equipment | 1.00 | Based on Medicare pricing |
Impact on Claimants and Employers
For injured workers, Indiana's schedule aims to provide prompt, fair reimbursement that mirrors Medicare rates, reducing disputes over underpayment. Employers benefit from predictable costs, as the schedule ties directly to a nationally recognized benchmark. However, providers should stay current on annual updates and any legislative changes that could alter conversion factors.
Staying Informed
The Indiana Workers' Compensation Board publishes the latest fee schedule on its website each January. Providers and employers should review the posted document, subscribe to updates, and verify that their billing software reflects the current rates to avoid claim rejections.