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Data: Drastic PPO Discounts Revealed

Data: Drastic PPO Discounts Revealed

It’s time to reveal what’s really harming injured workers in California.

Starting today, DaisyBill will publicize the reduced reimbursement rates foisted on our provider clients by Preferred Provider Organizations (PPO) and other discount contracting entities.

California establishes reasonable reimbursements with the Official Medical Fee Schedule (OMFS). In theory, OMFS rates should reflect the time and resources necessary to treat injured workers — generally about 130% of Medicare rates. In reality, PPOs and other discount contracting entities completely undermine that calculus, making workers’ comp an increasingly poor proposition for providers, and limiting injured workers’ options.

Why does any provider accept this state of affairs? Largely, it’s because providers are unaware of just how much revenue they’re losing this way.

Today, DaisyBill changes that.

PPOs & Discount Contracts: Driving Revenue Down and Providers Away

Our CA OMFS Reimbursement Reductions page breaks down the effect of contracted discounts in detail, for all bills with dates of service on or after January 1, 2021.

This is the big-picture view of how much revenue PPOs and other entities strip from 1,390 California providers who submit bills using DaisyBill software.

Our data reflects that DaisyBill California providers were owed over $84 million for treating injured workers since January 1. However, claims administrators paid only about $67 million for those services — representing a combined loss of over 20% for all our providers. DaisyBill updates the total revenue loss daily.

Our Discount page breaks this travesty down further, allowing the public to see detailed reimbursement data organized by:

  • Claims administrator
  • Billing code
  • Provider (each provider’s identifying FEIN number is masked to protect privacy)
  • Employer (each employer’s name is masked to protect privacy)
  • Fee Schedule - DaisyBill has data for 5 of the 7 OMFS fee schedule categories:
  • Professional Medical Services (Physician & Non-Physician Practitioners)
  • Ambulatory Surgical Centers (ASC)
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
  • Pharmacy
  • Pathology

These data are not exhaustive. The numbers represent all the workers’ comp bills electronically transmitted by DaisyBill providers to claims administrators, and roughly 88% of Explanations of Review (EOR) returned by claims administrators (about 12% of claims administrators refuse to provide electronic EORs, in violation of California law).

This is only one window into the broken nature of the California workers’ comp system. Is it any wonder providers are running for the hills?

DaisyBill makes authorization, payment, and appeals faster, easier, better. Contact us to learn how DaisyBill can save your practice thousands in revenue for workers’ comp services.


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