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Multiple Payors Reimbursing WC002 at 2017 Rates

June 1, 2018 by Catherine Montgomery

We’re halfway through 2018, and claims administrators are still reimbursing your office at 2017 rates for 2018 dates of service.

We’ve noticed this problem all year for various billing codes. We’ve called on claims administrators to update their systems to reflect California’s current Official Medical Fee Schedule (OMFS). Now, inexplicably, we see a particular code (WC002) paid at 2017 rates for 2018 dates of service — even as other codes on the same bill are paid correctly. 

Primary Treating Physicians (PTP) use California-specific code WC002 to bill for the Treating Physician’s Progress Report, either on form PR-2 or a narrative equivalent. Physicians should issue this report at least every 45 days, or more depending on patient progress.

For 2018 dates of service, Treating Physician's’ Progress Reports are reimbursable at a rate of $12.46.

Yet, we see repeated instances of claims administrators applying incorrect, outdated rates. See the Explanations of Review (EOR) below for examples of incorrect WC002 reimbursement from:

  • Broadspire
  • AmTrust North America
  • Mitchell International
  • Athens Administrators
  • SCIF
  • Berkshire Hathaway
  • Keenan & Associates
  • National Liability & Fire Insurance
  • Sedgwick
  • Insurance Company of the West
  • Zenith

These claims administrators reimbursed providers for PR-2 reports at 2017’s rate of $12.29. While $0.17 may not seem like a reimbursement crisis at the level of an individual charge, these reports are among the most commonly issued in workers’ comp.

Collectively, claims administrators are costing providers thousands.

No pattern of non-compliant underpayment — however big or small —  can be acceptable in a system that depends on consistently fair compensation for providers. Providers, be sure to produce thorough PR-2 reports. Bill compliantly, and check your office’s EORs to ensure receipt of appropriate payment for the date of service.

If your office does not obtain correct reimbursement from the claims administrators listed above, or from any claims administrator, request a second review appeal.

The only way to create a climate of compliance is to insist on it. Providers should accept nothing less than the appropriate reimbursement rate from claims administrators, every single time.



Having a hard time keeping up with ever-changing OMFS reimbursement rates? We can help. Use our popular OMFS Calculator, included with our Work Comp Wizard. Try it free by clicking the button below.

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