Author Topic: NEWBIE: how to calculate proper Workers Comp payments/ appeal underpaid claims?  (Read 2346 times)

thelakeshow2k

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i have a physician that wants me to appeal unpaid and underpaid workers comp claims.  is there a fee schedule (for california) to show what physicians should be paid?  i also saw this on the workers comp website:

To determine the maximum allowable reimbursement for a
physician service rendered after January 1, 2004 on or after July
1, 2004 the following formula is utilized: Relative Value Unit
Conversion Factor Percentage Reduction Calculation =
Maximum Reasonable Fee
before application of ground rules.


does that mean i have to do some calculating to determine what we should be getting reimbursed at?  if so, what do these terms mean and where do i find that info?  thank you!

Michele

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You should contact the state workers' comp board to see where to purchase a fee schedule for California.  You shouldn't have to calculate the fees, you should be able to obtain a schedule.

Michele
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DMK

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There is absolutely a W/C fee schedule for CA.  And if your doctor is in certain MPN's he is contractually obligated to take a reduced fee. 

There is also the "cascade".  The first procedure is paid at 100%, the 2nd at 75%, the 3rd at 50% etc.  You can also "time out" on procedures and modalities.

A key point too is that if you are not billing using the W/C fee schedule, you are NOT entitled to penalties and interest if you have to adjudicate a claim.

It's a messy, messy system, and not getting better (for the doctor or the patients).  Sorry.

ssherman

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There are multiple W/C fee schedules as the fee schedule will vary by locality.

Does the W/C reimbursement work the same way for Ambulatory Surgery Center's as for physicians?

Michele

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I'm not sure what you mean.  Are you asking if their are set amounts for ASC's as they have for physicians?
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ssherman

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Yes, and specifically if reimbursement follows the "cascade" 100/75/50/25% procedure payment?

Michele

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I am not sure, but I do believe it does.  Maybe somebody else has experience in this area.

Michele
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