York Misses the Mark: Paying 2019 Bills at 2018 OMFS 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.

2019 Physician Fee Schedule Changes

Effective January 1, 2019, the California Division of Workers’ Compensation (DWC) modified the Physician Fee Schedule for all dates of service occurring in 2019. This fee schedule is updated to include the adoption of Medicare Geographic Practice Cost Indices (GPCIs), which are complex and which we cover extensively in prior posts.

In addition to introducing the complexities of GPCIs, the DWC also updated California-specific codes. Annually, the California Division of Workers’ Comp establishes a single new statewide reimbursement for the services covered by these ‘WC’ codes.

Since the beginning of 2019, York has ignored these required 2019 reimbursement changes to the GPCI and California-specific WC codes.

York. Behind Every Blown Payment

The following two examples are representative of the many payments by York we found during our data analysis. In each example, York underpaid the provider by failing to apply the GPCI locality factor. Adding insult to injury is York’s incorrect reduction of WC002 payments, which the DWC set at a California-specific code reimbursement of $12.65 for dates of service in 2019, no matter where it’s performed. There is absolutely NO excuse for incorrectly paying the WC002 in 2019.

In this first example, for a date of service 1/8/2019:

  1. The York explanation of review (EOR) with a review date of 1/15/2019 shows that York incorrectly reduced the billed charges by using the 2018 reimbursement rates. York incorrectly reduced CPT 99213 by $109.42 and incorrectly reduced WC002 by $12.84.
  2. The incorrect reimbursements by York resulted in this provider receiving an underpayment for 2019 services in the amount of $4.20. This error reduced the provider’s reimbursement by approximately 4%. This amount may seem trivial, but add it to the many other payment mistakes, such as the one we discuss later in this article, and York’s mistake is costing providers thousands and thousands of dollars.

In this incorrect reimbursement example, York informs the provider that “Insurance Fraud Is A Crime And Is Punishable By Law.” York should heed its own warning. Given that there are many, many similar examples of incorrect reimbursement, York could be construed as engaging in a pattern of incorrectly reimbursing providers that treat injured workers.

What’s also noteworthy is that this is a bill for services rendered to an employee of a California fire district, one of those we should be thanking for their extraordinary efforts to keep us safe.

No injured worker should ever receive substandard care, but given York and other carriers’ patterns of underpayment, injured workers are fortunate any provider is willing to endure this payment friction in exchange for medical services.

In the second example, for a date of service of 1/9/2019:

  1. The York EOR with a review date of 1/30/2019 (a full month after the commencement of the new fee schedule) shows that the provider submitted a bill with charges actually equal to the amounts due per the 2019 Physician Fee Schedule. In other words, calculating the correct reimbursement requires NO math by Bill Review.
  2. Yet, the EOR again shows that York incorrectly reduced the billed charges by using the 2018 reimbursement rate.
  3. Even more horrifying, in blatant disregard of the new CPT codes (96130 & 96136) for psychological testing, York incorrectly disallowed payment for two new valid codes.
  4. The incorrect reimbursement by York resulted in this provider receiving an underpayment for services in the amount of $221.96. This error reduced the providers’ reimbursement by an astonishing 51%.

Cure Your Epidemic, York

As we illustrated in our coverage of Sedgwick’s misapplication of the 2018 OMFS rates to 2019 dates of service (DOS), providers should not be burdened with correcting a claims administrator’s epidemic of incorrect reimbursements. DaisyBillers have already submitted 4,137 bills to York for 2019 DOS, and unfortunately, the bills with a York “Reviewed Date” prior to 1/30/2019 indicate a systemic, month-long error. York needs to step in and offer a solution to providers.

We feel your frustration here at DaisyBill. That’s why we painstakingly update our software with the latest fee schedule updates, no matter how labyrinthine. Coupled with our efficient electronic billing platform, DaisyBill puts the power of knowledge at your fingertips. Most importantly, DaisyBill clients can easily submit fully compliant appeals in seconds with our intuitive software. We make securing the correct reimbursement simple and keep administrators on their toes.

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