A daisyBill client received a disturbing authorization document to treat an injured City and County of San Francisco (CCSF) employee. MTI America, a self-described “integrated network health solutions” company, sent the document, which:
Worse, the document included a statement declaring that the provider is locked into MTI’s payment terms whether or not the provider signs the agreement.
You read that right — MTI asserts that the provider agrees to its payment terms by simply receiving the faxed authorization document and rendering the services listed.
In California, no provider can treat an injured worker until the employer’s Utilization Review (UR) declares the proposed treatment medically necessary. MTI’s document arguably contorts UR by implying that authorization depends on the provider accepting onerous payment terms — a potentially dark new twist in UR and injured workers’ access to treatment.
We do not know whether CCSF is aware that MTI is sending these questionable, conditional authorization documents on CCSF’s behalf. However, all physicians should carefully review the following information and be on high alert for similar documents.
Spoiler: In this case, the requesting physician ignored the faxed agreement, forwarded the authorization to a provider who rendered the services, and sent the bills to CCSF — which paid for the services at fee schedule rates.
Typically, CCSF is an excellent example of a claims administrator that adheres to California workers’ comp laws and regulations. Our physician clients consistently report that CCSF is fair and reasonable, which has also been daisyBill’s experience with this public employer.
For an injured CCSF worker, the physician received a one-page “MTI - Medical Authorization” document approving six massage therapy sessions at a flat rate below the amount allowed by the California Official Medical Fee Schedule (OMFS).
The MTI authorization failed to list CCSF as the claims administrator, so there is no way to determine if this claims administrator knows about MTI’s shenanigans. In fact, we wonder whether MTI is empowered to authorize or deny treatment for CCSF employees.
MTI’s authorization demands that someone (we are unclear who exactly) sign the authorization document. However, the authorization also asserts that if no one signs the document and the services are provided to the injured worker, MTI discounted, onerous payment terms apply.
In a mind-bending disclaimer, MTI states the following [emphasis added]:
In addition to discounted reimbursement rates, the MTI authorization stipulates:
Finally, MTI also insists that the document and its terms be hush-hush, instructing that only MTI representatives and the “above listed vendor” be privy to this strange, secretive agreement.
Usually, we’d look at a contract like this and ask ourselves why any provider would sign it.
But in this case, it’s much worse. MTI converts UR into a payment trap by including contractual ambush language declaring the payment terms take effect with the receipt of an unsolicited, faxed document.
Providers, be careful. There’s no limit to the creative thinking that discount vendors apply to draining revenue from practices that treat injured workers — and California legislators have abandoned physicians subject to this type of duplicitous payment mischief.
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