PAYMENTS FOR MEDICAL REPORTS ARE DOWN 36.7%: doctors denied payment, workers denied access to care

In workcompcentral's issue of 29 January 2015 CWCI has formally admitted that payments for evaluation and management reports have been slashed by over one-third. CWCI now openly acknowledges  that a big bite has been taken out of consulting physicians evaluation services (the actual obtuse wording is in CWCI Research Update by Stacey L. Jones, January, 2015).

One of the methods used to deny injured workers fair review of their claims is to find a legal way not to pay for review of records or to discourage creation of the reports in the first place. Here is how it's done:

 1) separate reimbursement for non-face-to-face prolonged evaluation and management services is eliminated. This step means that a physician's review of medical records won't be paid for. This step in turn means that when physicians receive, say, 20  or 30 lbs. of medical records, they will not be paid for review of these records. 

2) The prolonged service code 99358 which was previously used to bill for reimbursement for the several hours it might take for review of records has been disallowed.

3) The workcompcentral article disclosing these changes says that doctors who are frustrated with the effort it takes carriers to pay have a choice: they can stop accepting injured workers as patients or they can accept fewer cases.

4) The workcompcentral story says that "doctors are no longer paid for time to review records and research literature to support a treatment request."

5) The workcompcentral story goes on to say that the current fee schedule "almost encourages the omission of medical records in the treatment review process" and that this step in turn means that carriers often deny treatment and force injured workers into the independent review process.

6) We know from previous stories in workcompcentral that Utilization Review denies 80% of treatment requests and that 80% of the time the rejection is upheld by Independent Medical Review (IMR).

7) For about one year there was an alternative to across-the-board denial of record review. Physicians who asked for consultations could file contracts pursuant to Labor Code 5307.11 in which pre-authorization could be requested along with a pre-negotiated fee arrangement. Under this code it was permitted to bill for 99358. For about a year, some adjusters who wanted a specific physician's report would sign the agreement. No longer is that the case. Physicians' offices are now routinely refused use of LC 5307.11 -- they're even told by adjusters that the word has come down from upper management that they may not authorize or otherwise approve use of LC 5307.11 contracts. In some venues this conduct might be seen as an illegal  restraint of trade but not in the workers comp field.

The law evidently allows management to declare a legal contract out-of-bounds. It may be here that there is an Achilles heel. Does the California Applicants Attorneys Association (CAAA) have an opinion? Or California Society of Industrial Medicine and Surgery (CSIMS)? or Voters Injured at Work (VIAW)?

8) For the time being, the door has been slammed shut not only on 99358 as a prolonged service code but also  on other related report codes. The slammed door is smack in the face of the injured worker. The upshot is that the injured worker's access to care has been slashed by a multitude of administrative decisions wrought by SB 863 which now appears to have caused more harm than good. We now have concurrence from CWCI as to how this unfortunate situation is unwinding.  What we don't have yet is a solution although repeal of SB 863 would be a step in the right direction.

INSIDER REPORT FOR WORKERS COMP CONSULTANT DOCTORS

REVIEW OF RECORDS UNDER CODE 99358 HAS BEEN DELETED
 
While this  report is aimed at doctors who are asked to do consultations for injured workers, its comments should be of interest to attorneys on both sides, insurance companies, adjusters, and injured workers. Most of the consultants who interview and examine  injured workers know by  now that Dr. Das, speaking for the administration at the workers comp hearing in Oakland earlier this month, told the audience that the doctors who do consultations should be "advocates" for their patients and should prepare their consultation reports free of charge. While well meaning, the remarks showed a lack of knowledge about how the system works. To begin with, consultations may also be requested by insurance companies, defense attorneys,  and adjusters, not just by injured workers, applicants, and their lawyers. Das' remarks would put the defense consultant in the position of  "advocating" for the insurance companies. In fact,, the consultant is supposed to provide an expert opinion as part of a search for truth. The consultant is  not supposed to "advocate" for anything but the truth as it is believed by the consultant.


As to the free-of-charge remark, Dr. Das didn't acknowledge that the transcription fee for these reports is often in excess of one hundred dollars. Providing such reports free-of-charge amounts to a subsidy for the insurance companies which works against injured workers' interests. More to the point, medical offices would find that shelling out a hundred bucks to provide "free" reports is the  straw that breaks the camel's back. The answer would be to stop doing consultations.  


Here's how the money part worked under the OMFS or Official Medical Fee Schedule with reference to consultations requiring review of records which would be billed under  Code 99358, now deleted as a billable code since January 1st.


99358  is, or was, the code number used to identify review of records, as in prolonged E & M services before and/or after patient care. Its standard reimbursement was $33.80 per unit. But the consultant would not be paid this amount because the insurance company would deduct $2.54 for what it called a "network" reduction, in other words, a payback to the MPN or Medical Provider Network which retained the consultant in the first place. Now that the code has been rescinded, the entire reimbursement to the consultant under 99358 has also been rescinded. Review of records may now enter a dark age of reduced enthusiasm. 


Readers should ask the workers comp division of the Department of Industrial Relations to provide transcripts of Dr. Das' remarks to determine whether or not her remarks were accurately presented in this column. Doctor Das is Medical Director of the California Division of Workers Compensation.