OAR 436-009-0018: Discounts and Contracts

(1) Discounts. (a) An insurer may only apply the following discounts to a medical service provider’s or clinic’s fee: (A) A fee agreed to under a fee discount agreement that conforms to this rule and has been reported to the director; or (B) A fee agreed to by the medical service provider or clinic under an MCO contract to cover services provided to a worker enrolled in the MCO. (b) If the insurer has multiple contracts with a medical service provider or clinic, and one of the contracts is through an MCO for services provided to an enrolled worker, the insurer may only apply the discount under the MCO’s contract. (c) Any discount under a fee discount agreement cannot be more than 10 percent of the fee schedule amount. (d) An insurer may not apply a fee discount until the medical service provider or clinic and the insurer have signed the fee discount agreement. (2) Fee Discount Agreements. (a) The fee discount agreement between the parties must be on the provider’s letterhead and contain all the information listed on Form 3659. Bulletin 352 provides further information. The agreement must include the following: (A) A statement that the medical service provider or clinic understands and voluntarily agrees with the terms of the fee discount agreement; (B) The effective and end dates of the agreement; (C) The discount rate or rates under the agreement; (D) A statement that the insurer or employer may not direct patients to the provider or clinic, and that the insurer or employer may not direct or manage the care a patient receives; (E) A statement that the agreement only applies to patients who are being treated for Oregon workers’ compensation claims; (F) A statement that the fee discount agreement may not be amended. A new fee discount agreement must be executed to change the terms between the parties; (G) A statement that either party may terminate the agreement by providing the other party with 30 days written notice; (H) The name and address of the singular insurer or self-insured employer that will apply the discounts; (I) The national provider identifier (NPI) for the provider or clinic; and (J) Other terms and conditions to which the medical service provider or clinic and the insurer agree and that are consistent with these rules. (b) Once the fee discount agreement has been signed by the insurer and medical service provider or clinic, the insurer must report the fee discount agreement to the director by completing the director’s online form. The following information must be included: (A) The insurer’s name that will apply the discounts under the fee discount agreement; (B) The medical service provider’s or clinic’s name; (C) The effective date of the agreement; (D) The end date of the agreement; (E) The discount rate under the agreement; and (F) An indication that all the terms required under section (2)(a) of this rule are included in the signed fee discount agreement. (3) Fee Discount Agreement Modifications and Terminations. (a) When the medical service provider or clinic and the insurer agree to modify an existing fee discount agreement, the parties must enter into a new fee discount agreement. (b) Either party to the fee discount agreement may terminate the agreement by providing 30 days written notice to the other party. The insurer must report the termination to the director prior to the termination taking effect by completing the director’s online form. The following information must be reported: (A) The insurer’s name; (B) The medical service provider’s or clinic’s name; and (C) The termination date of the agreement. (4) Other Medical Providers. (a) For the purpose of this rule, “other medical providers” means providers such as hospitals, ambulatory surgery centers, or vendors of medical services and does not include medical service providers or clinics. (b) The insurer may apply a discount to the medical provider’s fee if a written or verbal contract exists. (c) If the insurer and the medical provider have multiple contracts, only one discount may be applied. (d) If the insurer has multiple contracts with a provider and one of the contracts is through an MCO for services provided to an enrolled worker, the insurer may only apply the discount under the MCO’s contract.