Indiana Workers Compensation Fee Schedule: Rates, Billing, and Disputes

Indiana’s workers’ compensation fee schedule sets two ceilings on what medical providers can charge for treating a workplace injury: hospitals and surgical centers are paid at 200% of the applicable Medicare rate, and individual physicians and other non-facility providers are paid at the 80th percentile of charges in their community.¹ The employer and its insurance carrier pay the bill. The injured worker pays nothing.²

Under Indiana law, employers must furnish an attending physician and all related medical services and products to an injured employee free of charge, from the date of injury through the resolution of the claim.³ The Worker’s Compensation Board holds sole power to approve payment for all medical services provided under the system.²

Facility Rate: 200 Percent of Medicare

A “medical service facility” includes hospitals, hospital-based health facilities, medical centers, and ambulatory outpatient surgical centers.⁴ The facility and the insurer first attempt to negotiate a rate. If they cannot agree, the default cap is 200% of what Medicare would pay that facility for the same service on the same date.¹

The Board’s procedural guidance applies a 2.0 multiplier to the Medicare amount for both inpatient and outpatient hospital services, with no reduction for the copayments or deductibles a Medicare enrollee would otherwise owe. The same 2.0 multiplier applies to ambulatory surgery centers and critical access hospitals.⁵

Because the facility cap tracks Medicare, the numbers move whenever the Centers for Medicare and Medicaid Services updates its Physician Fee Schedule or facility payment rules. CMS publishes a final rule each calendar year adjusting those rates.⁶

Non-Facility Rate: 80th Percentile of Local Charges

Individual physicians, therapists, chiropractors, and other providers who do not qualify as medical service facilities are capped at what 80% of providers in the same community charge for the same service.¹ A billing review service collects charge data from providers in a geographic area and calculates the 80th percentile figure for each procedure code. If a bill lands at or below that figure, it gets paid. If it exceeds the 80th percentile, the insurer can reduce it to the ceiling.

The cap varies by geography because it reflects local charge data rather than a national benchmark. A specialist’s 80th percentile ceiling in Indianapolis may differ from the same specialist’s ceiling in a smaller community.

Implants and Prescription Drugs

Medical implants such as joint replacements and spinal hardware are reimbursed on a cost-plus formula: the actual invoice cost of the implant plus a 25% markup for handling and administrative overhead. That cap took effect in 2013.

Repackaged drugs cannot be sold for more than the average wholesale price established by the original manufacturer.⁷ The rule targets a billing practice where a provider or pharmacy repackages a generic medication into a smaller container and applies a steep markup. The Board also maintains a formulary that governs which medications may be prescribed for injured workers and under what conditions.⁸

Billing and Payment Deadlines

Providers must submit bills within 120 days of the date of service. Once an insurer or employer receives a bill, it has 90 days to pay it or contest it in writing with a specific reason for the denial.⁹

If the insurer requests additional documentation to support the bill, the 90-day clock pauses until the provider sends the records. A provider who misses the 120-day filing window risks losing the right to reimbursement for that service.

Travel and Mileage

When an employer sends an injured worker to a provider outside the county where the worker is employed, the employer must cover reasonable travel expenses, including mileage, food, and lodging.³ The mileage rate cannot exceed what Indiana pays its own state employees, currently $0.49 per mile.¹⁰

The out-of-county trigger matters. If the authorized provider sits within the same county where the worker is employed, mileage generally is not reimbursable.¹¹ If the travel causes the worker to miss work, the employer must also reimburse lost wages based on the worker’s average daily wage.³

You Cannot Be Billed for the Difference

Indiana law is explicit: the employee and the employee’s estate have no liability to a healthcare provider for payment for services obtained under the workers’ compensation system, and all claims for payment must be directed to the employer and its insurance carrier.²

A provider, or anyone acting on the provider’s behalf, is prohibited from knowingly collecting or attempting to collect payment from an injured worker, the worker’s estate, or the worker’s family members. If the Board finds a violation, it can impose a civil penalty between $100 and $1,000 for each occurrence.¹² The narrow exception is a good-faith error, such as a billing office that genuinely did not know the treatment was part of a workers’ compensation claim.

If a provider’s bill exceeds the fee schedule amount, the provider must absorb the difference. The provider cannot send the excess to you, place a lien on your assets for the shortfall, or report the unpaid balance to a collection agency. Any dispute over the payment amount is between the provider and the insurer.

How Providers Dispute a Payment

When a provider disagrees with the amount an insurer paid, the dispute goes to the Worker’s Compensation Board. The provider must file an application for adjustment of a medical fee claim within two years of receiving the insurer’s first written communication about the bill.² Applications involving a medical service facility in a balance billing dispute require a $60 filing fee. If the insurer paid nothing at all, no filing fee is required.

Providers can bundle up to ten individual claims into a single application, provided all claims involve the same employer or insurer and no individual claim exceeds $200.² The Board evaluates whether the billed amount falls within the applicable fee schedule cap and can order additional payment if the insurer underpaid.

Refusing Treatment After a Permanent Impairment

One consequence sits outside the fee schedule but worth flagging. After a permanent partial impairment has been established, if the employer continues to offer treatment aimed at limiting or reducing the impairment and the employee refuses it, all compensation payments stop for the duration of the refusal, and the right to pursue further proceedings is suspended until the refusal ends. The employer must first serve written notice in a form prescribed by the Board.³

1
Indiana General Assembly. Indiana Code 22-3-3-5.2 – Billing Review Service Standards
2
Indiana General Assembly. Indiana Code 22-3-3-5 – Pecuniary Liability of Employer
3
Indiana General Assembly. Indiana Code 22-3-3-4 – Medical Treatment Pending Adjudication of Impairment
4
Indiana General Assembly. Indiana Code 22-3-6-1 – Definitions
5
Worker’s Compensation Board of Indiana. Procedural Guidance on Hospital and Medical Facility Charges
6
Centers for Medicare & Medicaid Services. Physician Fee Schedule
7
Business Insurance. Indiana Workers Comp Reform Includes Rules for Repackaged Drugs
8
Worker’s Compensation Board of Indiana. Formulary
9
Legal Information Institute. 631 IAC 1-1-32 – Medical Provider Fee Claims
10
Indiana Department of Administration. Travel Reimbursement Rates
11
State of Indiana. As an Injured Worker Can I Be Reimbursed for Mileage?
12
Worker’s Compensation Board of Indiana. Compliance