California healthcare providers are not to blame for the state’s grotesquely expensive and inefficient workers’ comp system. Yet, some commentators can’t help but push that narrative.

The latest scapegoating focuses on “unlisted” billing codes that providers use to bill for complex treatments like Functional Restoration Programs (FRPs).

An FRP is a multidisciplinary program to address chronic pain that hasn’t yielded to more conservative treatments. By nature, FRPs require intricate coordination among specialists to develop individualized approaches for workers with different injuries, occupations, pain levels, tolerances, cognitive functioning, emotional regulation, and other variables.

The pundits accusing providers of rampant overbilling ignore the following facts:

• California law requires providers to submit a Request for Authorization (RFA) to obtain payer approval prior to furnishing an FRP program.
• California’s Medical Treatment Utilization Guidelines recommend FRPs where appropriate.
• On multiple occasions, Independent Medical Review (IMR) has overturned payers’ FRP denials. In fact, IMR overturns FRP denials at more than double the overturn rate for all treatments generally.

FRPs are not a loophole, scam, or opportunity for “creative” billing practices. Instead, these programs are widely recognized as a legitimate, if more complex, approach to restoring injured workers to health.

Payers Authorize FRPs

The authorization document below is one of many that payers have sent to daisyBill clients approving an FRP for an injured worker.

In this and other cases, both the RFA and the authorization document explicitly state that an FRP is the medically appropriate course of treatment. Note that the authorization below acknowledges the complexity of the proposed FRP, which includes:

• Educational material
• Physical reconditioning/functionals
• Psycho-physiological autogenic training
• Medical/medication management
• Vocational counseling

Crucially, the provider did not request approval for these treatments individually; they requested them as components of an FRP. The request and approval specify the amount of treatment and time limitations; in this case, the payer approved 80 hours of the FRP in question.

Because FRPs are multifaceted and vary in their specific combination of treatments from patient to patient, it would be impossible to establish a universal reimbursement rate. Instead, providers bill for the approved FRP hours using CPT 97799, a “By Report” (BR) code.

Per California Official Medical Fee Schedule regulations, to determine the reimbursement rate for a BR code, the doctor provides an “adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary…” The provider must furnish a separate report justifying the charges.

A payer that receives a bill for an FRP should not be surprised.

The FRP treatments, including the number of hours, is exactly what the payer (or IMR) actively affirmed as necessary for the injured worker. Throughout an FRP, the Primary Treating Physician must provide detailed clinical session notes and progress reports.

IMR Supports FRP

IMR is the process by which an injured worker appeals a payer’s Utilization Review (UR) decision to deny the care that their treating physician recommends. Maximus Federal Services, Inc. is the designated independent reviewer for all IMR cases.

As the California Division of Workers’ Compensation (CA DWC)’s most recent IMR report shows, Maximus rarely overturns a payer’s decision to deny a treating physician’s recommended care.

On average, IMR has upheld about 90% of treatment denials since 2016.

Putting aside what the statistics above say about the IMR process generally, the unmistakable reality is that it is exceedingly difficult to get Maximus to overturn a UR denial…which makes it all the more significant when Maximus does so.

In the IMR decision below, Maximus issues one of its rare overturns, compelling insurer The Hartford to authorize an FRP.

The above is just one among many examples.

In fact, as the CA DWC IMR report shows, Maximus overturned 22% of FRP denials; that’s more than double the 10% overturn rate for all treatments generally.

If FRPs were some frivolous fee schedule loophole by which providers could gouge payers, Maximus would be extremely unlikely to affirm their medical necessity and appropriateness so frequently compared to other treatments, especially given the rarity of ‘Overturn’ decisions generally.

FRPs are valid, and California’s fee schedule mandates exactly how to bill for them using CPT 97799. Providers are required to meticulously design, document, and substantiate the details of an interdisciplinary treatment approach, which payers routinely authorize and that IMR has upheld hundreds of times.

While provider overbilling does occur and should not be excused, it’s time to drop the “overbilling providers” boogeyman narrative and recognize that getting California’s comp costs under control starts with cutting needless administrative expenses, not impugning the integrity of doctors.

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