Does One Call violate 4906G? (California)

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Does One Call violate 4906G? (California)

Postby steve appell on Mon Mar 20, 2017 1:51 pm

IS THIS A 4906G VIOLATION?

http://www.crossroadstoday.com/story/34 ... ll-medical

Above is the LINK to the article/law suit, and below is some language from the pleading

OCM has developed an opaque, unfair and illegal scheme whereby OCM maximizes the compensation it receives from its payor clients by referring injured workers to those of its contracted health care professionals who accede to the deepest discount. This system is nothing like a traditional “Preferred Provider Organization” (“PPO”) where the PPO contracts with health care providers payors let their beneficiaries choose to receive services from any of the health care providers who contract with the PPO, and then the payors pay the claims submitted by those contracted providers. OCM does not offer health care professionals the opportunity to be listed in a directory. Rather, OCM solicits (or extorts) deep discounts of a specified amount from its contracted health care professionals as an inducement for it to send them a specified number of additional referrals. Similarly, unlike traditional PPO arrangements, injured workers are not free to select a care provider from among the contracted health care professionals. Rather, OCM assigns injured workers to the provider of OCM’s choosing, thus further ensuring it maximizes its revenue by assigning these injured workers to the providers who have acceded to the deepest discounts. In doing so, OCM illegally provides them a preference in receiving such referrals. The payment OCM receives from its workers’ compensation payor clients for its management services is tied to the number of referrals OCM makes and the size of the discounts OCM obtains from its contracted health care professionals who care for injured workers.
Steve

appellandassociates.com
6311 Van Nuys Bl #480
Van Nuys, Ca 91401
wcexaminer@aol.com


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Re: Does One Call violate 4906G? (California)

Postby LawAdvocate on Tue Mar 21, 2017 9:06 am

Sounds like some people like to play the victim. If you do not agree with OCM's pricing policies, why would you become a member of their network? If every provider just said no, OCM would fail to exist. You can't extort anything in this fact scenario, when you have the right to say no.
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Re: Does One Call violate 4906G? (California)

Postby steve appell on Tue Mar 21, 2017 9:30 am

Sorry LA, but I think you missed my point. If my PTP recommends an MRI which is UR approved, and the IC says we will authorize "ONLY" through OCM and does not allow me to pick any other MRI in the MPN due to cost, that is classic 4906G. AND BTW .... if the MPN does not have 3 MRI's in a reasonable geographic area of the IW, it is also my belief that the MRI outside the MPN is compensable .... at fee schedule of course.
Steve

appellandassociates.com
6311 Van Nuys Bl #480
Van Nuys, Ca 91401
wcexaminer@aol.com


Check out 'WORK COMP MATTERS" Free PODCAST below
https://www.workcompcentral.com/educati ... ype=online
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Re: Does One Call violate 4906G? (California)

Postby LawAdvocate on Tue Mar 21, 2017 9:51 am

The IC has no right to say they only authorize One Call, they can ask for referrals to a One Call provider, however that is a mere suggestion and unenforceable. There is no code that allows this type of "authorization"

I agree that if an MPN is in play, the usual rules for providers applies.

However, if there is not an MPN in play or the MPN does not provide required choices, the physician can refer to the MRI or other diagnostic, PT facility of choice. However the PTP better document the heck out of that because mere internet searches are not evidence. It has to be authenticated at the time any diagnostic lien becomes an issue for trial. I can't wait until MRI companies start pulling the PTP's staff out of their offices to authenticate that they printed out the internet search on that day and there were not 3 MRI facilities within a reasonable geographic distance and then they called the MPN coordinator to verify they had conducted the search correctly and the MPN coordinator verified and did not offer the name of three MRI facilities within a reasonable geographic distance.

I have impeached those internet searches too many times to count, because of a faulty search method and no one to authenticate the piece of paper they are waiving around the courtroom like the Louisiana Purchase. If they aren't authenticated by testimony under penalty of perjury, how do I know they weren't modified. Even I am capable of that, not that I would bother.
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Re: Does One Call violate 4906G? (California)

Postby vampireinthenight on Wed Mar 22, 2017 8:26 am

Authentication... pffft, who needs that? This is WC! :lol:
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