[Noah930]

It's not just the state/MediCal that's screwing you. I found out today that non-govt insurers are underpaying me. I do a lot of worker's comp. As you know, to be "recognized" as a provider by an insurance company (private or WC) you have to be on their MPN (Medical Provider Network). Most if not all WC insurers require you to be on Blue Cross before they will allow you into their WC MPN. For WC in CA, there is an official fee schedule (OMFS). The WC insurers are supposed to pay based upon that fee schedule. This past January, there was actually an increase (!) in reimbursement for things like hand and foot in the OMFS (though there was a general decrease for most other types of procedures). I thought that would be a good thing for me.

But in talking to my billing staff today, I have realized that this year the WC insurers have started paying me based upon Blue Cross rates...because they rationalize that I am a Blue Cross provider. This is not a mistake on their part. They are selecting the lower fee schedule (Blue Cross) for their payments. So despite the supposed increase in the WC fee schedule that I thought I'd realize, I'm actually making less this year than last. Conveniently for them, last year they paid the WC fee schedule, as it reimbursed less than Blue Cross.

And this year, rolled into the sweeping reimbursement changes in WC, is another new gem: all appeals must be filed within 90 days, or else the statute of limitations expires. So my billing staff has to be very on-the-ball to review every single payment that comes in (in a timely fashion) and to see if it's been paid on the proper WC fee schedule, or based upon Blue Cross rates. Very sneaky on the insurance companies, huh? We're planning on renegotiating our contract with Blue Cross to reword our agreement so close this "loophole" the WC insurers are using.