There’s a worrying trend that workers’ comp doctors in California are facing increasingly often: Incorrect Preferred Provider Organization (PPO) reductions that slash their revenue and consume administrative resources.
In theory, workers’ comp providers are protected by the California Labor Code, which sets rules to “prevent the improper selling, leasing, or transferring of a health care provider’s contract” and ensure that reductions are applied only when backed by a contract.
The reality can be very different, though. After submitting a workers’ comp bill, providers often receive Explanations of Review (EORs) from payers where reductions are improperly applied without even citing the contract — because it doesn’t exist.
As a result, many providers are unfairly reimbursed below the rates set forth by California’s Official Medical Fee Schedule (OMFS).
There are procedures in place to deals with situations like these (namely, Second Review Appeals and Independent Bill Reviews), however, many workers’ comp providers lack the administrative expertise or the resources to navigate these processes.
Incorrect PPO Reductions: What to Do
No doubt, this is a concerning trend. Even more worrisome, there’s no clear solution in sight from government regulators. It falls upon the workers’ comp providers to find ways to protect their revenue while maintaining the efficiency of their practice.
Thanks to our extensive experience with medical-legal billing, at Practice IQ, we can help you take steps to limit the risk of incorrect PPO reductions. And if an incorrect reduction takes place, we can also assist you in seeking the proper reimbursement for your services.
If you believe that this is not a problem affecting your practice, think again. This is a widespread issue; if you haven’t noticed it in your organization, chances are good that you are losing revenue without even realizing it.
Looking for Medical-Legal Billing Services in California? Contact Practice IQ
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