Blog: DaisyBill News

Last week, we opened Pandora’s box on co-surgeons and team surgery. Notably left in the box was a discussion on assistant(s) at surgery. Typically this arises when physicians or non-physician practitioners assist during a procedure, but don’t perform any surgery.

To qualify for reimbursement, the California regulations are more ambiguous and require more documentation than required for co-surgeons and team surgery.

Today we report on the responses from Sedgwick, Liberty Mutual, York, and State Compensation Insurance Fund (SCIF), following our posts detailing their systematic underpayment of 2019 workers’ comp medical bills.

We identified these four claims administrators in our series of articles alerting readers to the incorrect underpayments of bills for 2019 dates of service (DOS) in California. These claims administrators non-compliantly reimbursed providers by using the lower-paying 2018 fee schedule.

This underpayment “error” resulted in many, many thousands of underpaid Physician Services bills.

Surgery in workers’ compensation cases opens a Pandora’s box: reserves go up, nurse case managers get involved, and surgeons need to justify every detail of their billing to a non-physician. Getting an extra set of hands to help in the operating room compounds the frustration and reimbursement for the assistant surgeon can be confusing.

Fortunately, the California Official Medical Fee Schedule (OMFS) follows Medicare’s manual, almost word for word. Here, we present a handy guide to billing for surgical assistance.

When navigating the seas of change, it’s refreshing to find an island of relative stability. Like California’s state-specific codes, the splinting and casting codes group (commonly referred to as “Q codes”) is not subject to the Geographic Practice Cost Index (GPCI) adjustment and is only adjusted quarterly with the DWC adoption of the Medicare rates.

Not one to avoid the spotlight, York Risk Services joins Sedgwick CMS in incorrectly applying the 2018 Physician Fee Schedule rates to services rendered in 2019. Our data show a consistent and demonstrated pattern of botched payments through at least the end of January.

Despite the vastly increased complexity of the California Physician Fee Schedule in 2019, most administrators are abiding by the changes and issuing checks for the appropriate amounts. A few stragglers remain who, for whatever reason, fail to follow the new schedule. Today, we turn our attention to York Risk Services.

With the flurry of new year fee schedule changes, California updated the Physician Fee Schedule reimbursement for its state-specific codes. These codes are explained in 8 CCR §9789.12.14 by the Division of Workers’ Compensation (DWC) and reimbursement is updated annually. Thankfully, the reimbursement formula is straightforward and not subject to variation by locality.

In the Physician Fee Schedule, the state-specific codes cover services for which there are no appropriate CPT codes, such as the Primary Treating Physician’s Progress Report (DWC form PR-2). Annually, the California DWC establishes a single new statewide reimbursement for each of the services covered by these ‘WC’ codes.

Since the beginning of 2019, Sedgwick CMS has incorrectly used the 2018 Physician Fee Schedule to reimburse providers. Our data indicates that Sedgwick is consistently and incorrectly reimbursing providers for 2019 dates of service.

While the California Physician Fee Schedule is infinitely more complex in 2019, many claims administrators are correctly reimbursing providers. But some are not.

On a regular basis, this blog will bring to light the claims administrators that repeatedly and non-compliantly reimburse providers the wrong amount for services rendered in 2019. Today, we commence with Sedgwick.

The 2019 changes to California’s reimbursements got your head spinning? Here’s a handy reimbursement cheat sheet for the most frequently used Evaluation & Management codes.

Use this to start grappling with Medicare Geographic Practice Cost Indices (GPCIs), newly implemented for the workers’ comp Official Medical Fee Schedule (OMFS) as of 1/1/2019.