Kansas Workers Compensation Fee Schedule: Billing and Disputes

The Kansas workers’ compensation fee schedule caps what providers, insurers, and self-insured employers can charge or pay for medical treatment of a work injury at the lesser of the provider’s usual charge or the amount listed in the state’s published schedule of medical fees. That rule comes from K.A.R. 51-9-7.¹ The Kansas Department of Labor’s Division of Workers Compensation publishes and updates the schedule; the current version is the 2024 schedule of medical fees, effective May 3, 2024.²

What the Schedule Covers

K.A.R. 51-9-7 governs fees for medical, surgical, hospital, dental, and nursing services, along with medical equipment, supplies, prescriptions, medical records, and medical testimony provided under the Kansas Workers Compensation Act.¹ Practically any billable service or product tied to a work injury falls under the schedule’s caps, from an emergency room visit to a pair of crutches to a physician deposition.

K.S.A. 44-510h backs this up by requiring the employer to furnish healthcare services, surgical and hospital treatment, nursing, medicines, supplies, ambulance transport, crutches, apparatus, and reasonable transportation to reach treatment.³ Whatever the employer must furnish gets reimbursed at the schedule’s maximum rates.

How the Lesser-Of Rule Works in Practice

Every reimbursable service is paid at the lower of two numbers: the provider’s usual and customary charge, or the fee schedule amount.¹ A provider who normally charges less than the schedule rate collects their regular charge. A provider who charges more gets capped at the schedule amount. The injured worker should not face a balance bill for the difference.

Because the department updates rates periodically to reflect changes in Medicare values and state economic conditions,² providers and payers should always confirm they are working from the version currently posted on the KDOL website. The schedule includes ground rules for each category of treatment and an appendix, all adopted by reference within the regulation.

How the Dollar Amounts Are Built

Kansas bases its schedule on the Resource-Based Relative Value Scale (RBRVS), the same framework CMS developed for Medicare.² Each procedure has a relative value unit reflecting physician work, practice expense, and malpractice risk. Kansas then multiplies the RVU by a state-specific conversion factor to produce the dollar amount.

Conversion factors differ by service category. Surgery uses one multiplier, office evaluation another, radiology another. The actual conversion factor amounts appear inside the fee schedule document and change when the schedule is updated. When CMS adjusts national RVUs, those changes eventually flow through into the Kansas numbers. The formula is reproducible: look up the CPT code, find its RVU, apply the applicable conversion factor, and you have the maximum reimbursable amount.

Pharmacy Reimbursement

Prescriptions run on a separate formula. Instead of RBRVS, Kansas pays based on Average Wholesale Price, with different adjustments and dispensing fees for brand and generic drugs. Brand-name drugs are generally reimbursed at AWP minus 10% plus a $3.00 dispensing fee. Generics are reimbursed at AWP minus 15% plus a $5.00 dispensing fee. The lesser-of rule still applies: the payer owes the lower of the schedule amount or the pharmacy’s usual charge.

Physician-dispensed and repackaged medications require prior approval from the carrier and are reimbursed based on the original manufacturer’s National Drug Code, not the repackaged label. Compounded medications follow the same approach.

Billing the Right Way

Getting paid depends on matching the right codes to the right documentation. Providers must assign accurate CPT and HCPCS codes for each service. ICD-10-CM diagnosis codes need to be specific enough to link the treatment directly to the work injury, and many carriers want secondary or tertiary codes describing how the injury happened.

Coding has to be backed by medical records that support both the treatment performed and the complexity level billed. Individual practitioners typically submit on the CMS-1500; hospitals and institutional providers use the UB-04. A mismatch between the billed code and the record is the fastest route to a denial or downward adjustment.

The full schedule, including category ground rules and the appendix, is available on the KDOL website.² The ground rules contain category-specific billing instructions that go beyond the CPT manual, and they are worth reading before submitting.

Payment Timeline and Reconsideration

K.S.A. 44-510j puts a clock on the payer. Within 30 days of receiving a bill, the employer or carrier must either pay or send a written notice giving the specific reason the bill was refused or adjusted. That notice has to tell the provider that additional information may be submitted and that reconsideration may be requested.⁴

If a provider disagrees with a denial or adjustment, the provider has 30 days from receiving the written notice to submit a reconsideration request with supporting information.⁴ Miss that window and money gets left behind. Calendar it the moment a dispute notice arrives.

Formal Fee Disputes

When informal exchanges do not resolve the disagreement, there is a formal path. If a provider sends a bill and gets no response within 30 days, then sends a second bill and still gets no response within 60 days of the original submission, the provider can apply for an informal hearing before the Director of Workers Compensation.⁴

K.S.A. 44-510i separately gives the Director authority to establish rules for appeals and review of disputed charges or services.⁵ The Director’s decision resolves the disputed amount. Providers going into a hearing should bring detailed billing records, the applicable CPT and ICD-10 codes, supporting documentation, and a clear explanation of how the billed amount aligns with the published schedule.

The statute also requires that the maximum fees be “reasonable” and “promote health care cost containment and efficiency” within the workers’ compensation system.⁵ That gives the Director some flexibility for unusual services that do not map neatly onto a standard CPT code.

Two Boundaries Worth Knowing

The schedule assumes the carrier authorized the treatment. The employer or insurance carrier selects the authorized treating providers.⁶ An injured worker can consult a doctor of their own choosing without prior approval, but the employer’s liability for that independent consultation is capped at $800, and that consultation cannot be used to obtain a functional impairment rating; a rating obtained in violation of that restriction is inadmissible.³

The obligation to pay for treatment is also not indefinite. Kansas presumes the employer’s duty to pay for medical care ends when the injured worker reaches maximum medical improvement.³ Continuing care after MMI is possible but has to be established under standards set in the statute, and bills submitted for post-MMI care without that showing will not be honored under the schedule.

Finally, if the case settles and the injured worker is on Medicare or expects to enroll within 30 months, CMS may need to review a Workers’ Compensation Medicare Set-Aside Arrangement. CMS reviews these when the claimant is already on Medicare and the total settlement exceeds $25,000, or when future Medicare enrollment is expected and the settlement exceeds $250,000.⁷ The set-aside funds future medical expenses Medicare would otherwise pay; getting the number wrong can shift future costs onto the claimant.

1
Legal Information Institute. Kansas Administrative Regulations 51-9-7 – Fees for Medical and Hospital Services
2
Kansas Department of Labor. Medical Services and Fee Schedule
3
FindLaw. Kansas Code 44-510h – Medical Treatment and Healthcare Provider Services
4
Kansas State Legislature. Kansas Code 44-510j – Payment of Medical Bills and Dispute Resolution
5
Kansas Office of Revisor of Statutes. Kansas Code 44-510i – Medical Benefits, Maximum Medical Fee Schedule, Advisory Panel
6
Kansas Department of Labor. Injuries at Work
7
Centers for Medicare & Medicaid Services. Workers’ Compensation Medicare Set Aside Arrangements