Once again, a claims administrator — with the help of a Preferred Provider Organization (PPO) — offers a perfect example of what makes treating injured workers financially unsustainable for California providers.

For a standard Evaluation and Management (E/M) visit, Third-Party Administrator (TPA) Athens Administrators paid a physician only $157.03 for their medical services. Meanwhile, Athens paid the interpreter who translated during the medical evaluation $220.00.

Undoubtedly, the interpreter’s vital services were worth every dime of the fee schedule rate they received. That acknowledged, here are two cold, hard monetary facts that should concern California physicians:

1. Physicians are routinely paid significantly less than the interpreters in the room.
2. In this case, Athens used a PPO discount contract to pay the physician 29% less than the interpreter.

Even without PPO discount carnage, California workers’ compensation fee schedules guarantee that physicians often receive lower reimbursements for conducting medical services than the interpreters who facilitate those services.

• In the case of this evaluation, the California Physician Fee Schedule sets the reimbursement rate at $196.29 for the doctor conducting the evaluation.

• The California Interpreter Fee Schedule sets the reimbursement rate at $220.00 for the translation services provided during this medical evaluation.

• California workers’ comp fee schedules reimburse interpreters approximately 11% more for translation than physicians are reimbursed for medical evaluations.

While interpreters should be well-compensated commensurate with their important role, physicians certainly deserve no less. Many physicians already understand this (along with other cold, hard monetary facts) and have stopped treating injured workers.

How long until the remaining physicians also revolt? Doctors have plenty of options, and treating injured workers seems increasingly like the least favorable.

Physician Takes Triton PPO Hit

The physician evaluated the injured worker and prepared the mandatory Treating Physician’s Progress Report (for the record, this was after completing undergraduate studies, graduate studies, and medical school, which required an obscene cost in both time and money).

As noted above, California’s Physician Fee Schedule reimburses $196.29 for an evaluation like this, as billed with Current Procedural Terminology (CPT) code 99214.

But as Athens’ Explanation of Review (EOR) below shows, Triton Healthcare PPO took a $39.26 bite of the physician’s reimbursement, leaving the physician with $157.03 —  equivalent to just 80% of the California Physician Fee Schedule rate.

As Triton Healthcare’s website shows, the only “service” Triton provides is a “data processing platform” for “claims repricing.” In other words, unlike physicians, Triton does nothing to help injured workers recover. Yet California allows Triton to “reprice” this physician’s bill and reduce payment to 20% below the amount allowed by the Physician Fee Schedule.

The interpreter (quite rightfully) received the full fee schedule reimbursement of $220.00, as shown in the EOR below. Of course, the interpreter’s critical services were worth that amount. But it is no less accurate to state that the physician who performed the evaluation should also be compensated per fee schedule rates — at the very least.

California workers’ comp fee schedules pays physicians less than interpreters for their respective roles during the same service. PPO discounts widen that indefensible pay gap even further, ensuring that physicians receive rates significantly below interpreters’ reimbursement.

California allows these “data processing platforms” to gut physician revenue, enriching PPOs off the backs of those who actually treat injured workers. As physicians flee the workers’ comp system, no one can blame them for exercising their options.

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