The DWC, the Physician Fee Schedule, and Align Networks

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The start of the new year is always a hectic time in the world of California workers’ compensation. Often prior to January 1st, California’s Division of Workers’ Compensation (DWC) posts an order adjusting the Physician and Non-Physician Fee Schedule to conform to the Medicare payment system. Not so in 2017. As of January 4, the DWC has not yet made such an adjustment.

Without an order from the DWC, the 2016 Physician and Non-Physician Fee Schedule remains in effect for all 2017 dates of service.

Unfortunately, Align Networks is prematurely directing its providers to use new Medicare physical therapy CPT codes for dates of service on or after January 1, 2017. Even though the DWC has not adopted these new codes, Align has sent an email to providers stating that failure to bill these unadopted CPT codes “can result in delay in processing and/or denial of [the] claim.”

Further muddying the water, the Align-mandated physical therapy codes are new CPT codes without a calculated reimbursement in the current 2016 Physician and Non-Physician Fee Schedule. Accordingly, it is impossible for a provider to know the reimbursement for these Align-mandated physical therapy CPT codes since the DWC has not adopted a reimbursement for these codes.

Essentially, it appears that Align expects workers’ comp providers to send Align bills with the unadopted physical therapy CPT codes. Subsequently, Align (instead of the DWC) will determine the reimbursement for these CPT codes.

Bottom line: We recommend that providers closely read their contracts with Align to determine their rights, as well as the anticipated reimbursement for their services. Further, we encourage providers not to use these Align-mandated CPT codes when billing California claims administrators, as these CPT codes have not been adopted by the DWC and therefore are not associated with a reimbursement amount.

As soon as the DWC posts an order adjusting the Physician and Non-Physician Fee Schedule to conform to the Medicare payment system, DaisyBill will perform an analysis and integrate the new rates into our OMFS Calculator. Until then, check out our analysis of the new DMEPOS fee schedule, and watch for a post on the new Path/Lab schedule coming tomorrow. In the meantime, happy billing – we’ll be back with more updates as the new year unfolds.

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