Work Comp Problems/Possible Solution

[Guest guest]

In recent posts, there has been a discussion regarding workers’ compensation fees being capped by a certain chiropractic panel company. The chiropractic panel company has apparently been marketing themselves to insurance companies as a means of cutting costs based on their participating providers. In Oregon, the only way to operate in the fashion that this chiropractic panel company has been operating is as an MCO. This chiropractic panel company does not meet the Oregon definition of an MCO according to the Workers’ Compensation Dispute Resolution Team. As such, regardless of what “civil†contracts have been signed and agreed to, they do not supersede the laws applying to Oregon Workers’ Compensation (again, according to Workers’ Compensation Dispute Resolution Team).

We had a case involving three workers who were involved in an on-the-job motor vehicle accident. Billings were sent to the workers’ compensation insurance company, who unbeknownst to us had an agreement with this chiropractic panel company and in turn forwarded the bills on for processing. Reimbursement reflected a cap at the chiropractic panel company workers’ compensation daily limit, which was significantly different than the submitted charges for services performed. This chiropractic panel company had no problems with the proposed treatment plan. They had provided an anticipated dollar amount “cap†of what would be the maximum that would be paid out per patient under the specific diagnoses, but still applied their daily per diem limitation.

On questioning the level of reimbursement, we were advised this is what the company had established as an agreed upon rate. Realizing that tis chiropractic panel company was operating as an MCO and did not meet that definition, the matter was brought to the attention of the Workers’ Compensation Division Dispute Resolution Team who reported they have had a variety of problems with this company in their attempt to apply a PPO standard to the State definition of an MCO. The Worker’s Compensation Dispute Resolution Team in turn took our complaint forward and placed a lien on the workers’ compensation insurance carrier. This action caught somebody’s attention because within days of the lien being put in place, the carrier was in touch with our office and signed an agreement under the auspices of the Dispute Resolution Team to pay for medically reasonable and appropriate services that had been submitted per the Oregon Workers’ Compensation fee schedule. The agreement stipulated resolution within 30 days of the date of the document.

The carrier in turn passed the matter on assuming that it would be addressed. It went back to the chiropractic panel company who offered roughly a 50-percent payment on the agreed upon outstanding balance. They went on to say they were not responsible for the balance of it, which should have been addressed by the insurance carrier’s other claims processing system through Concentra. After approximately six weeks of bantering the issue back and forth and repeated faxes of CMS-1500 forms, the chiropractic panel company was still stalling payment.

The matter was taken back to Workers’ Compensation Dispute Resolution Team who stated in light of the circumstances and the past history, they were prepared to issue sanctions against the panel company’s third party administrator as well as the workers’ compensation insurance carrier. Simultaneous to the action of the Workers’ Compensation Division, the representative from the insurance carrier contacted our office quite apologetic reporting she was unaware of what was happening with the claims processing with this chiropractic panel company, specifically in the delaying tactics and the effort to pay less than the full and agreed upon reimbursement and payment was received within one week of this last episode.

The Workers’ Compensation Dispute Resolution Team is there to assist you in such matters, providing guidance, and in this case, intervening with a non-compliant carrier. If you are encountering similar problems and assuming you have appropriate clinical documentation meeting all the criteria established under the Administrative Rules applicable to workers’ compensation cases, and have clearly established the medical necessity and performed reasonable and appropriate services, you should be utilizing this valuable service available to providers in work-related injuries.

They can be reached at Department of Consumer and Business Services, Workers’ Compensation Division, Resolution Team – Medical Section, 300 Winter Street N.E., or P.O. Box 14480, Salem, Oregon 97309-0405. Telephone: (503) 947-7537.

I hope you find this helpful.

Tom Freedland, DCIt's Tax Time! Get tips, forms and advice on AOL Money Finance.