Some Claims Administrators Continue to Pay at Old Fee Schedule Rates

Some Claims Administrators Continue to Pay at Old Fee Schedule Rates

On March 1st the new Physician OMFS for California workers’ comp took effect. DaisyBill’s data indicates some claims administrators continue to reimburse bills using the old fee schedule rates--usually for amounts lower than currently allowed.

Given the complexities of network contract discounts, a reliable manner to identify incorrect reimbursement is an analysis of the reimbursement amount for WC002.

Since March 1st, our data shows that 29 claims administrators reimbursed WC002 at the old fee schedule rate of $11.91 instead of at the new increased reimbursement of $12.0, effective 3/1/2015 . Accordingly, we analyzed the bills associated with the incorrect WC002 reimbursement, and we determined that in many instances there was incorrect reimbursement for all of the CPT codes contained on the bill.

Providers, check every reimbursements for dates of services as of March 1st. For incorrect reimbursements, remember to submit a timely Second Bill Review (SBR) within the mandated 90 days of receipt of the Explanation of Review (EOR).

For incorrect reimbursements we recommend using the following SBR reason for additional payment:

Per Regulations §9789.12.1, et seq. additional payment due per the OMFS Update for Physician and Non-Physician Services - Effective March 1, 2015

For easier fee schedule calculations, try the DaisyBill Calculator:

Try the OMFS
Calculator (FREE)

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