Workers’ Compensation Medical Fee Schedules in the U.S. (2025 Guide)

Workers’ Compensation Medical Fee Schedules in the U.S. (2025 Guide)

Workers’ Compensation Medical Fee Schedules

Workers’ Compensation Medical Fee Schedules



Everything employers, insurers, medical providers, and injured workers need to know

Workers’ compensation medical costs represent one of the largest expense areas for employers and insurers. To control costs and ensure fair reimbursement, most states use a Workers’ Compensation Medical Fee Schedule—a state-regulated pricing system that sets maximum payment amounts for medical services related to workplace injuries.

In 2025, nearly every state continues to update fee schedules regularly, aligning more closely with Medicare’s RBRVS system, telehealth rules, and pharmacy cost controls. This guide breaks down how fee schedules work, which states use them, and what’s new for 2025.

What Is a Workers’ Compensation Medical Fee Schedule?

A workers’ compensation medical fee schedule is a set of maximum allowable reimbursement rates for medical services, tests, procedures, drugs, hospitals, and durable medical equipment (DME) provided to injured workers.

Its purpose is to:

  • Control excessive billing

  • Reduce claim costs

  • Prevent overcharging

  • Provide predictable reimbursements

  • Standardize care delivery

  • Ensure injured workers still receive quality medical treatment

Because workers’ compensation is state-regulated, each state creates its own fee schedule, leading to significant variation from one state to another.

Why Fee Schedules Matter in Workers’ Compensation

Understanding fee schedules is essential for risk managers, adjusters, medical billing teams, and attorneys. A state’s fee schedule affects:

  • Medical costs per claim

  • Provider willingness to treat injured workers

  • Billing disputes and utilization review activity

  • Claims duration and settlement value

  • Access to specialists like orthopedists and pain management

States with no medical fee schedule typically have higher medical costs per workers’ comp claim.

States Without a Workers’ Compensation Medical Fee Schedule (2025)

As of 2025, six states do not use a statewide workers’ compensation medical fee schedule:

  • Indiana

  • Iowa

  • Missouri

  • New Hampshire

  • New Jersey

  • Wisconsin

In these states, providers commonly bill using:

  • Usual and Customary Rates (UCR)

  • Charge-based billing

  • Negotiated contracts

These states consistently report some of the highest average medical costs per claim in the country.

How States Structure Their Workers’ Comp Medical Fee Schedules

1. RBRVS (Medicare-Based) Fee Schedules

Used by the majority of fee-schedule states.
Examples: California, Texas, Florida, North Carolina, Michigan, Oregon, Arizona

RBRVS ties reimbursement to Medicare’s resource-based values but usually includes

  • higher conversion factors,

  • additional multipliers, or

  • state-specific rules.

2. Custom State-Specific Fee Schedules

Examples: New York, Massachusetts, Washington, Oregon

These states create their own tables, independent of Medicare.
They tend to be more complex but allow more control over specialty categories.

3. Percent-of-Charges Fee Schedules

Examples: Alabama, Mississippi

Providers bill full charges, and insurers pay a set percentage.

4. Fair Health / Purchased Data Tables

Examples: Georgia, Tennessee

These rely on commercial medical pricing databases to determine allowable amounts.

5. Hybrid Systems

Some states use multiple methodologies across:

  • physicians

  • hospitals

  • ASCs

  • pharmacy

  • DME

  • behavioral health

State-by-State Fee Schedule Comparison (2025)

Below is a simplified summary of how states classify their workers’ comp fee schedules.

States With a Fee Schedule:

44 states + Washington, D.C.
Most of these use RBRVS-based systems for physician services, with variations for hospital, outpatient, and pharmacy rules.

States Without a Fee Schedule:

  • Indiana

  • Iowa

  • Missouri

  • New Hampshire

  • New Jersey

  • Wisconsin

Workers’ Comp Medical Services Covered by Fee Schedules

A fee schedule may include separate rules for:

✔ Physician Fees (CPT/RBRVS)

  • Office visits

  • Surgery

  • Physical therapy

  • Pain management

  • Anesthesia

✔ Hospital Inpatient / Outpatient (DRG/APC based)

States often adopt modified Medicare DRG/APC systems.

✔ Ambulatory Surgical Centers (ASC)

May use ASC groups or custom tables.

✔ Pharmacy Fee Schedules

Regulate:

  • Generic vs. brand reimbursement

  • Opioid prescribing limits

  • Compounded pharmaceuticals

  • Maximum allowable cost (MAC) programs

✔ Durable Medical Equipment (DME)

Often tied to Medicare fee schedules.

✔ Telehealth (New for 2024–2025)

Most states now include telehealth billing rules for:

  • Virtual visits

  • Follow-up care

  • Psychological evaluations

2025 Trends in Workers’ Comp Medical Fee Schedules

1. Greater Alignment With Medicare

More states adopt Medicare’s structure but raise conversion factors to maintain provider access.

2. Stronger Pharmacy Controls

States continue reducing opioid spending by tightening prescription rules and lowering reimbursement for brand drugs.

3. Telehealth Integration

Telehealth reimbursement stabilizes post-pandemic, with many states making temporary rules permanent.

4. More Frequent Updates

Annual or semiannual updates reduce disputes and close loopholes.

5. Cost Containment Pressure

Employers and insurers push for simplified billing rules and reduced charge-based payments.

Download: Workers’ Comp Fee Schedule Table (2025)

You can download the full table created earlier:

👉 Download CSV — WC Fee Schedule by State (2025)

This includes:

  • Every state + DC

  • Whether a fee schedule exists

  • Primary reimbursement method

  • High-level classification


Workers’ Compensation Medical Fee Schedule FAQ (2025)

1. What is a Workers’ Compensation Medical Fee Schedule?

A workers’ compensation medical fee schedule is a state-specific set of rules that defines the maximum amount medical providers may bill for treating an injured worker. It regulates costs for physician services, hospitals, surgery centers, pharmacy, DME, and telehealth.

2. Do all U.S. states have a workers’ comp medical fee schedule?

No. As of 2025, six states do not have a statewide fee schedule:
Indiana, Iowa, Missouri, New Hampshire, New Jersey, and Wisconsin.
These states typically rely on Usual and Customary Rates (UCR) or negotiated pricing.

3. Which states have the strictest medical fee schedules?

States like California, Texas, New York, Massachusetts, Oregon, and Washington are known for highly detailed, frequently updated schedules with strict billing and documentation rules.

4. How are fee schedules determined?

Most states base reimbursement on one or more of the following:

  • RBRVS (Medicare-based values)

  • Custom, state-designed tables

  • Fair Health commercial databases

  • Percent-of-charge formulas

  • Hybrid systems covering different service types

5. How often are workers’ comp fee schedules updated?

It varies by state, but many update:

  • Annually (California, Texas, Oregon)

  • Quarterly or semi-annually for hospital or pharmacy updates

  • As-needed for conversion factors or telehealth rules

6. Do workers’ compensation fee schedules cover telehealth?

Yes. Most states now include telehealth within their workers’ comp fee schedules, with regulations on billing codes, place-of-service modifiers, and reimbursement parity compared to in-person visits.

7. How does Medicare influence workers’ comp reimbursement?

Dozens of states use Medicare’s RBRVS or DRG/APC systems as a base.
However, workers’ comp usually pays higher than Medicare to ensure provider access and compensate for administrative complexity.

8. What medical services are included in fee schedules?

Commonly regulated categories include:

  • Physician/office visits

  • Surgery

  • Physical therapy

  • Radiology (X-ray, MRI, CT)

  • Anesthesia

  • Inpatient/outpatient hospital care

  • Ambulatory surgical centers

  • Pharmacy (generic and brand)

  • Durable medical equipment (DME)

  • Telehealth
    Some states also regulate chiropractic care, dental services, and transportation mileage.

9. What happens in states without a fee schedule?

Health providers may bill their full customary charges, and insurers negotiate payments or apply UCR tables. Costs in these states are typically higher and vary more widely.

10. How do fee schedules impact workers’ comp claim costs?

Fee schedules reduce variation and prevent overcharging. States with strong fee schedules generally have:

  • Lower average medical costs

  • Fewer billing disputes

  • More predictable claims outcomes

  • Faster return-to-work timelines

11. Are hospital fees included in workers’ comp fee schedules?

Yes, but hospitals often follow separate systems such as:

  • DRG-based (inpatient)

  • APC-based (outpatient)

  • State-specific per-diem rates
    Hospital reimbursement rules can be more complex than physician fee schedules.

12. Where can I download a state-by-state workers’ comp fee schedule list?

You can download the CSV file generated earlier in this session:
👉 [WC Fee Schedule by State (2025) – Download] (sandbox:/mnt/data/wc_fee_schedule_by_state_2025_highlevel.csv)

Conclusion

Workers’ compensation medical fee schedules remain one of the most important cost-containment tools in the U.S. system. With 44 states and Washington, D.C. maintaining active schedules—and only six states relying on UCR billing—fee schedules continue to shape costs, provider behavior, and claim outcomes.


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