Lately, we’ve noticed a problem. Some claims administrators are reimbursing providers incorrectly. Instead of paying the higher 2018 Official Medical Fee Schedule (OMFS), claims administrators are paying last year’s lower 2017 reimbursement rates for services rendered this year. This is not acceptable. In these cases, it’s up to the provider to protect their revenue.
Fortunately, there are tools for providers to calculate — and obtain — proper reimbursement.
Protect Your Bottom Line
Burdensome though it is, workers’ comp providers have to be vigilant about obtaining correct reimbursement. When the employer or insurer’s claims administrator / bill review makes a mistake, it’s on the provider to discover and correct it. Two months into the new year, and it appears we can’t assume that claims administrators will apply 2018 reimbursement rates when appropriate.
This can put a notable dent in revenue, if left unaddressed.
Reimbursement for almost every one of the most often-used procedure codes went up for 2018 dates of service (only one code, surgery CPT Code 17004 for destroying premalignant lesions, pays less this year than last). Most rose modestly, anywhere between 1 and 7 percent, though the largest increase (for CPT 64555 for implanting neuroelectrodes) was by 83%, a difference in payment of $1,468.81.
These increases add up! Over time, even losing the more modest differences due to payor mistakes can mean significant loss of revenue.
Obtaining Correct Reimbursement
To ensure proper, compliant payment of bills, every provider office should do two things:
- Closely review bills for correct payment for services rendered in 2018. If the date of service is on or after January 1, check the reimbursement against the 2018 OMFS.
- When the claims administrator incorrectly applies 2017 rates to 2018 dates of service, submit a compliant request for second review. We suggest including the following language:
"California’s Official Medical Fee Schedule was updated for all dates of service on and after 1/1/2018. This service rendered in 2018 was incorrectly paid using the prior 2017 reimbursement rates. The correct reimbursement is $XX.XX. Please immediately reprocess for an additional payment of $XX.XX due per the fee schedule update."
In our experience, second review is usually enough to resolve these errors, though providers may request Independent Bill Review (IBR) if second review fails to produce proper reimbursement.
With some claims administrator payment systems still in need of updates to reflect new reimbursements, staying on top of this problem is an unfortunate necessity. We can’t say how long it will be until all payor systems are up to date, so providers, stay vigilant. As always, we’ve got your back.