Obstacles Facing Doctor's Office (California)

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Obstacles Facing Doctor's Office (California)

Postby Manila on Fri Dec 20, 2019 8:13 am

17 Obstacles Facing a Doctor's Office Working in the California Workers' Compensation System

1) Insurance Company changing the address of the claims office without notifying doctor's office

2) Insurance Company assigning a new claim number to a claim transferred to a different claims office without notifying the doctor's office resulting in rejection of bills

3) High frequency of insurance company claiming they never received a bill

4) High frequency of insurance rejecting a bill claiming there is no "documentation" when the required report documenting each and every charge is attached to the bill

5) High frequency insurance companies do not reply to a "Provider's Request for a Second Bill Review" within mandated time frames.

6) Extraordinary frequency with which insurance companies do not reply whatsoever to a "Provider's Request for a Second Bill Review."

7) Extraordinary frequency with which Bill Review Departments of insurance companies down code procedure codes while ignoring documentation for each procedure code

8) Attempted calls to Bill Review companies thwarted by no telephone number or having telephone representatives field calls with no authority to do anything other than to pass on a message

9) Narrative reports from doctors expected by insurance companies with no authorization for payment

10) Denial of bills for reports requested by claims adjusters with the explanation there is no pay for a doctor reviewing his chart.

11) Insurance companies excluding doctors from their panel of doctors unless the doctor agrees to a large discount in fees.

12) Insurance companies authorizing a doctor for an out-of-network consultation with no PPO discount and their bill review department nonetheless applying a PPO discount.

13) Bill review company insisting PPO discount is correct even when the doctor's office is authorized for an out-of-network consultation with no PPO discount.

14) Having to compile a mass of documentation for an IBR review accompanied by a $195.00 check with a 50% chance IBR will generate an incorrect decision.

15) Having insurance companies ignore and refuse to reimburse doctor's office the $195.00 fee when IBR rules in the doctor's office favor.

16) Insurance company delisting a doctor from their MPN without notifying the doctor's office leading to denial of charges for weeks to months after coincidentally learning of the delisting.

17) Refusal of insurance company to pay for progress reports from secondary treating doctors.

18) Insurance companies impertinently lumping doctors into the category of "providers" and worse yet "vendors."
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Re: Obstacles Facing Doctor's Office (California) (California)

Postby jpod on Fri Dec 20, 2019 9:22 am

I agree 1 through 17, if provable, represent bad behavior and only increase the frictional costs in the system.

I don't get number 18. If you object to being labeled a vendor b/c of insurance company failures 1 through 17 maybe I can see your point. If not I don't understand your objection.

A vendor, also known as a supplier, is an individual or company that sells goods or services to someone else in the economic production chain.

The economic production chain we are discussing is a mandated state system for the provision of workers' compensation. Employers are required to provide WC coverage for its employees; the State has set up a system for the provision of workers' compensation. If you provide medical treatment to an injured worker you are providing a service to the employer to help it fulfill its obligation to provide workers' compensation benefits. The term vendor applies to that business relationship; it does not extend to the relationship between the injured worker and the person with the degree/license that allows them to provide whatever service they are licensed to provide to the patient. In fact it is forbidden to involve the patient in any way with the business side of the relationship between the employer and whomever is dispensing the workers' compensation benefit that is due the employee.

edited to delete the word "to" in "due to the employee"
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