The Workers Compensation Research Institute (WCRI) published a new study examining payment and utilization patterns for medical services that do not have established fee schedule reimbursement rates and how those trends vary across states.
Forty-four states and the District of Columbia use medical fee schedules to reimburse medical services, yet many common services continue to be reimbursed outside of these fee schedules.
The study focuses on durable medical equipment (DME) and professional services billed by nonhospital providers delivered between January 1, 2019, and June 30, 2025, within workers’ comp systems with fee schedules.
This study represents approximately 99.5% of workers’ comp benefits paid nationwide. Medical payments per claim grew in nearly all study states from 2022-2025, primarily driven by growth in prices for medical services, along with inflation. However, faster growth in medical prices was seen in states that updated their fee schedules based on measures of inflation, rather than a medical price index.
Across jurisdictions with fee schedules, half of DME services lacked an assigned fee schedule rate in 2025, accounting for 62% of total DME payments. A small number of codes accounted for the majority of DME services without fee schedules – E1399 (miscellaneous DME) and E0607 (intermittent limb compression device) accounted for half of DME payments without fee schedules.
Utilization of DME services reimbursed outside fee schedules increased between 2019 and 2025, with the median share of DME spending for these services increasing from 58% to 63%, while more than half of jurisdictions experienced growth in the share of payments for these services.
Nonhospital professional services without fee schedules accounted for 4.8% of total payments, yet only 1.7% of services, demonstrating that they were more expensive than the average professional service. From 2019-2025, the expenditure share of nonhospital professional services without assigned fee schedule rates rose from 3.8% to 4.8%, even though utilization remained stable.
Neurological/neuromuscular testing accounted for 29% of payment share, while pain management injections accounted for 12% of payment shares, making up the two largest components of payments in services without fee schedule rates in 2025. Physical medicine and major surgery also had notable levels of reimbursement outside fee schedules.
In many fee schedule states, more than 95% of professional service payments were for services with established fee schedule rates. However, 12 jurisdictions reported payment shares for services without fee schedule rates ranging from 5% to 38%.
The increase in payment shares for DME and professional services without fee schedule rates likely contributed to the recent increase in medical payments. One significant reason for these fee schedule gaps is that many of these services are not commonly reimbursed by Medicare, as many states use Medicare rates as a basis for workers’ comp fee schedules.
As states continue to evaluate workers’ comp medical costs, this research highlights where services are being reimbursed outside established fee schedules and may inform future policy discussions around medical payment oversight.
