It happens every year: Reimbursement rates for workers’ compensation services in California change, and payers reimburse providers at the lesser, previous rates.

It happens 365 days a year: Providers are the victims of an exploitative triple-punch, financial blows dealt by payers and enabled by California’s current workers’ comp system.

For the bill described below, Broadspire owes the provider $220.72 at Official Medical Fee Schedule (OMFS) rates for Evaluation and Management (E/M) services and reporting. Instead of reimbursing the provider correctly, Broadspire reimbursed the provider $121.97. Broadspire paid the provider 47% below OMFS rates, a loss to the provider of $98.75.

The employer of this injured worker is Pentair. We wonder if this employer knows that Broadspire fails to properly reimburse providers who treat injured Pentair employees?

Broadspire and the Exploitative Triple-Punch

This provider, like so many others, is a victim of an unprincipled financial triple-punch that allowed Broadspire to take $98.75 from the provider’s reimbursement:

1. No Consequences: Broadspire reimbursed the provider $36.45 below the amount that is allowed by the OMFS for the services rendered. California law imposes no consequences against Broadspire for failing to properly reimburse this provider.

2. Financial Incentives: Broadspire will keep the provider’s $36.45 reimbursement if the provider fails to submit a Second Review appeal or if the provider fails to pay $180 to submit an Independent Bill Review (IBR). Broadspire is financially incentivized to incorrectly reimburse this provider.

3. Network/PPO Looting: Broadspire plundered the provider’s reimbursement and took $62.30 from the provider to pay Anthem Blue Cross. The amount Broadspire paid to Anthem Blue Cross is 51% of the amount paid to the provider. Anthem Blue Cross furnished no services to the injured worker. Why is Broadspire giving Anthem Blue Cross $62.30 of the provider’s reimbursement????????????????????????

Broadspire Pays $62.30 to Anthem Blue Cross Instead of Provider

In addition to failing to properly reimburse the provider per the OMFS, Broadspire also paid Anthem Blue Cross $62.30 that Broadspire deducted from the provider’s reimbursement.

Broadspire is out of compliance in applying outdated reimbursement rates to the wrong dates of service. Just as infuriating is the technically compliant — but baseless — gift of the provider’s revenue from Broadspire to Anthem Blue Cross.

We know neither the injured worker nor the provider benefit from the payment to Anthem Blue Cross. Does the injured worker’s employer, Pentair, benefit from the $62.30 Broadspire paid Anthem Blue Cross? Does Pentair know that Broadspire is paying Anthem Blue Cross instead of paying the provider who treated Pentair’s injured employee?

It is mind-numbing that California allows payers to use networks to fleece its workers’ compensation system with such impunity.

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