November 19, 2025 | SIBTF.org — The California Department of Industrial Relations (DIR), through its Division of Workers’ Compensation (DWC), has announced new adjustments to the Official Medical Fee Schedule (OMFS) covering services provided by hospital outpatient departments and ambulatory surgical centers (ASCs). These updates, which align with the latest quarterly changes from the Centers for Medicare & Medicaid Services (CMS), are effective for services rendered on or after October 1, 2025.
Why This Matters to SIBTF Cases
For claimants and practitioners involved with the Subsequent Injuries Benefits Trust Fund (SIBTF), these regulatory fee‐schedule changes influence how medical services are reimbursed under workers’ compensation. Lower or revised reimbursement rates for outpatient or ASC services may affect overall cost projections, settlement strategy, and future medical expense planning.
What’s Changing & When It Applies
DWC’s Order (dated November 14, 2025) formalizes the October 2025 Medicare‐aligned revisions to surgical procedure codes (HCPCS) for ASCs and ambulatory surgical settings.
These adjustments took effect for all services rendered beginning October 1, 2025. Practically, this means that claims for outpatient hospital or ASC services after that date must adhere to the updated fee schedule.
Strategic Implications for Claimants
1. Revisit medical cost projections
If you’re involved in a SIBTF claim, now is a good time to reassess anticipated medical costs in light of the new fee schedule. Changes may reduce reimbursement for certain services so your future medical expense estimates could require updating.
2. Settlement timing considerations
Because fee schedule changes took effect as of October 1, 2025, timing of service delivery (or settlement offers) may affect cost basis. For those contemplating lump‐sum settlements through the SIBTF, referencing the most current reimbursement expectations becomes critical.
3. Coordination with healthcare providers
Ensure your treating outpatient facilities and ASCs are aware of the new code and rate structure. Misalignment between billed services and the updated schedule could lead to delays or denials, impacting your overall claim handling.
4. Monitor future updates
Fee schedules are adjusted quarterly to align with federal changes. Staying current with DWC announcements ensures your strategy remains aligned with regulatory shifts.
Next Steps for Claimants & Representatives
- Review recent Outpatient/ASC services in your claim to confirm fee‐schedule compliance.
- Consult with your medical provider or billing specialist to identify any codes impacted by the change.
- Discuss with your SIBTF counsel whether these changes influence your settlement strategy or future medical cost reserve.
- Bookmark the DWC OMFS updates page for future announcements.
Taking these steps ensures that your SIBTF claim remains fully compliant and strategically positioned. Staying informed about fee schedule changes, coordinating with medical providers, and reviewing your settlement approach can help protect your benefits and optimize financial outcomes. Proactive management of your claim now can prevent surprises later and support a smoother resolution process.
Read more at DWC Posts Additional Adjustments to OMFS.
If you’re involved in a SIBTF matter, subscribe to SIBTF.org for timely updates on fee schedules, regulatory developments, and settlement strategy insights. Also, for the original DWC announcement and full details of the fee schedule adjustments.
Read More from SIBTF.org:
- When Is the Right Time to Request a Lump Sum in an SIBTF Case?
- California Governor Orders Urgent Reform Plan for Second-Injury Fund
- SIBTF Reform 2026: Newsom Urges Comprehensive Overhaul
FAQs: Understanding OMFS Updates and Impacts on SIBTF Claims
What is the Official Medical Fee Schedule (OMFS)?
The OMFS is the standardized payment schedule set by DWC governing reimbursement rates for medical treatment in workers’ compensation for various settings (physician, hospital outpatient, ASC, inpatient, etc.).
How do the changes affect SIBTF lump‑sum calculations?
Since future medical expense projections are a component of SIBTF evaluations, a change in reimbursement rates alters your cost baseline, which in turn can impact the “combined condition” value and timing of settlements.
Are outpatient services the only category affected?
No. While this specific order addresses hospital outpatient departments and ASCs, DWC issues updates for physician services, inpatient hospital services, DMEPOS (durable medical equipment, prosthetics, orthotics, supplies), and other categories on separate dates.
When will the next fee‑schedule update occur?
Updates follow CMS quarterly payment changes; stakeholders should watch for DWC announcements (typically posted shortly after federal updates). The next revision could be effective in early 2026 depending on CMS release schedules.
What is SIBTF?
The Subsequent Injuries Benefits Trust Fund (SIBTF) helps California workers who suffer a new workplace injury and already had a prior disability. It offers supplemental compensation when combined impairments severely limit earning capacity.