As costs skyrocket, physicians flee the system, and injured workers find it harder and harder to find a doctor willing to treat them, California workers’ comp has yet to reckon with its biggest systemic problem: the double standard between doctors and payers when it comes to compliance with workers’ comp law.
For an example, you can’t do better than recent failures by the City of Pasadena.
Pasadena, due to an error, is failing to process electronic workers’ comp bills as required by California law. After switching its third-party administrator (TPA) to Acclamation Insurance Management Services (AIMS), Pasadena left doctors unpaid indefinitely — without consequence.
Meanwhile, if a doctor fails in any aspect of compliance with billing rules, or is a day late in submitting an appeal, the consequence is automatic: denial of payment. Full stop. No appeals, no recourse, no payment for treating an injured worker.
Pasadena Switches to AIMS, Chaos Ensues
In August, we reported that the City of Pasadena (a self-insured employer) stopped processing provider e-bills after switching TPAs, from Adminsure to AIMS.
For unknown reasons, the TPA switch threw a monkey wrench into the gears at Lien On Me, halting bill processing. That’s according to a Lien On Me executive, who claimed that Pasadena’s electronic Payer ID was “suspended due to” the TPA change.
Why a change of TPA would be impossible for a bill review vendor to navigate is not clear. Nor does it matter, frankly.
What matters is that California law, since 2012, requires payers to process doctors’ e-bills. Mandatory electronic payment is a logical and crucial step forward for a system that struggles with inefficiency. As of this writing, Pasadena has failed to pay 130 DaisyBill provider e-bills.
The Compliance Double Standard
Errors happen. Systems and human beings fail to comply with rules and expectations. But one thing threatening the entire system by which California restores injured workers to health is the double standard that punishes doctor errors, and forgives (read: ignores) errors made by payers.
As we’ve reported a hundred different ways, workers’ comp is becoming increasingly unsustainable for California doctors. Simply put, state-mandated reimbursement rates per the Official Medical Fee Schedule (OMFS) are barely adequate to account for the time and administrative resources necessary to do business. And that’s before revenue is slashed by network discounts and losses due to payers’ failure to follow the rules.
That’s not to say workers’ comp cannot be sustainable and profitable for doctors. The system can work for everyone — patients, doctors, employers, and insurers — but only if all parties are held to a common standard.
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