Workers Compensation Fee Schedule Calculator 2025
Medicare Base Rate:
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State Conversion Factor:
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Geographic Adjustment:
1.00
Work RVU:
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Practice Expense RVU:
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Malpractice RVU:
0.00
Total RVUs:
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Per Unit Amount:
$0.00
Maximum Allowable Fee
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For 1 unit(s) in California
View Official Medicare Fee Schedules and Payment Guidelines
What is a Workers’ Compensation Fee Schedule?
Think of a workers’ compensation fee schedule like a price menu at a restaurant. It shows how much doctors can charge when they treat workers hurt on the job.
Simple Definition: A fee schedule is a list of set prices for medical care. It tells doctors and hospitals what they can charge injured workers.
Why do we need fee schedules? • Keep medical costs fair • Make sure doctors get paid • Same prices for everyone in the state
Each state makes its own rules. The state updates prices each year. All doctors must use these prices for work injuries.
How Workers’ Compensation Medical Fee Schedules Work
Here’s how it works step by step:
- Worker gets hurt – Someone gets injured at work
- Go to doctor – Worker goes to see a doctor
- Doctor treats injury – Doctor helps fix the problem
- Doctor sends bill – Doctor uses special codes to bill for services
- Insurance pays – Insurance company pays the set price from the fee schedule
The doctor cannot charge more than what’s on the fee schedule. If their normal price is higher, they still get the lower amount.
Types of Services Covered by Fee Schedules
Fee schedules cover many types of medical help. Here’s what’s included:
| Service Type | What’s Covered | Examples |
|---|---|---|
| Doctor Visits | Any time you see a medical professional | First visit after injury, follow-up appointments, emergency room care, specialist visits |
| Surgery | Operations to fix injuries | Fixing broken bones, removing damaged tissue, joint replacement, surgical tools and equipment |
| Therapy | Help getting better and stronger | Physical therapy, occupational therapy, chiropractic care, massage therapy |
| Tests & Scans | Pictures and tests to see what’s wrong | X-rays, blood tests, MRI scans, CT scans, ultrasounds |
Each service has a set price. The fee schedule tells everyone exactly how much each type of care costs.
Workers’ Compensation Fee Schedule by State 2025 (Complete State-by-State Breakdown)
Workers’ compensation fee schedules control how much doctors can charge for treating injured workers. Every state sets different maximum rates, creating huge cost differences across America. The national average is $1.03 per $100 of payroll in 2025.
What Fee Schedules Cover:
- Doctor visits and specialist consultations
- Surgery and hospital procedures
- Physical therapy and rehabilitation
- Prescription medications
- Medical equipment and supplies
2025 Key Changes:
- 15 states updated their fee schedules in January 2025
- Medicare-based states automatically increased rates by 2.6%
- California implemented new complex surgery guidelines
- Electronic billing becomes mandatory in 8 more states
States with Highest Workers’ Compensation Medical Rates (2025)
These states have the most expensive workers’ comp medical costs:
Top 5 Highest-Cost States:
- California – $2.40 per $100 payroll
- Uses complex OMFS (Official Medical Fee Schedule)
- Frequent updates every 6 months
- Special rules for different medical specialties
- New York – $1.89 per $100 payroll
- 140% of Medicare rates for most services
- Mandatory electronic billing starting August 2025
- Higher rates for NYC metropolitan area
- New Jersey – $1.65 per $100 payroll
- Mandatory coverage for all employers
- No opt-out options available
- High conversion factors applied
- Montana – $1.58 per $100 payroll
- State monopoly system drives costs up
- Limited competition among providers
- Massachusetts – $1.42 per $100 payroll
- Above-average reimbursement rates
- Complex billing requirements
Why These States Cost More:
- Higher cost of living increases medical rates
- Stricter coverage requirements
- Limited insurance competition
- More generous benefit structures
States with Lowest Workers’ Compensation Medical Rates (2025)
These states offer the most affordable workers’ comp costs:
Top 5 Lowest-Cost States:
- Maryland – $0.35 per $100 payroll
- Consistently ranked #1 for affordability
- Efficient state oversight system
- Streamlined fee schedules
- Virginia – $0.41 per $100 payroll
- Simple, easy-to-understand fee structure
- Regular competitive market reviews
- North Carolina – $0.44 per $100 payroll
- State-managed system controls costs
- Monopoly system creates predictable rates
- Utah – $0.47 per $100 payroll
- Business-friendly regulations
- Competitive insurance marketplace
- Arizona – $0.52 per $100 payroll
- Balanced approach to coverage
- Regular rate reviews keep costs down
Money-Saving Features:
- Competitive insurance markets
- Efficient claims processing
- Lower cost of living reduces medical costs
- Business-friendly regulatory environments
States Using Medicare Fee Schedule as Basis (2025)
Over 30 states base their workers’ comp rates on Medicare fee schedules with conversion factors:
Common Conversion Rates:
- 110-120% of Medicare (Most Popular): Florida, Georgia, Texas, Ohio
- 100-109% of Medicare (Budget-Friendly): Maryland, Virginia, Tennessee
- 121-140% of Medicare (Higher Rates): Illinois, Pennsylvania, Michigan
- 141%+ of Medicare (Premium Rates): New York, Connecticut, Hawaii
Medicare-Based System Benefits:
- Automatic annual updates (2.6% increase for 2025)
- Uses proven RBRVS (Resource-Based Relative Value Scale)
- Reduces administrative costs for states
- Creates consistency with federal healthcare standards
2025 Medicare Updates:
- All Medicare-based states got automatic 2.6% rate increase
- New CPT codes added for telehealth services
- Updated facility vs. non-facility payment differences
- Enhanced mental health service coverage
States with Custom Fee Schedules (Non-Medicare):
- California (OMFS system)
- New York (hybrid approach)
- Michigan (unique state-developed rates)
- Washington (state fund system)
Workers' Comp Schedule Fee 2025 - Top FAQs
What is a workers' compensation fee schedule?
A workers' compensation fee schedule sets payment rates for medical services. It tells doctors how much they get paid. The schedule covers all medical treatments for work injuries. Each state has its own fee schedule rules.
How often do workers' comp fee schedules get updated?
Most states update fee schedules every 1-2 years. Updates ensure fair rates and control healthcare costs. Some states make small changes annually. Check your state's labor department for exact dates.
What medical services are covered in the 2025 fee schedule?
Fee schedules cover ambulance fees, medical equipment, hospital services, lab work, drugs, and doctor visits. Physical therapy and surgery are included too. Most work-related medical care has set rates. Emergency care also follows the schedule.
How do I find my state's workers' comp fee schedule rates?
Visit your state's labor department website first. Look for the workers' compensation section. Most states post current fee schedules online. You can also call your state's workers' comp office.
Can doctors charge more than the fee schedule allows?
No, doctors cannot charge above fee schedule rates. The rates are maximum amounts allowed. Doctors must accept these as full payment. Billing above the schedule is against the law.
What happens if a medical bill exceeds fee schedule limits?
The insurance company pays only the scheduled amount. The doctor cannot bill you extra. Medical fee disputes can be submitted through secure systems. The excess amount gets written off completely.
Are prescription drugs included in workers' comp fee schedules?
Yes, prescription medications have set reimbursement rates. Pharmaceuticals are covered in the fee schedule. Generic drugs usually cost less than brand names. Prior approval may be needed for expensive drugs.
How do fee schedules affect my workers' comp claim?
Fee schedules don't change your right to treatment. They only control how much gets paid. You still get all necessary medical care. The schedule helps keep costs reasonable for everyone.
What CPT codes are used in workers' comp billing?
Fee schedules use five-character CPT codes from the American Medical Association. These codes describe each medical procedure. Doctors use CPT codes on all bills. Each code has a specific payment rate.
Who can I contact about fee schedule questions?
Contact your state's workers' compensation office first. Many states have special fee schedule mailboxes for questions. You can also call your insurance company. Medical providers have billing specialists who help too.