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Aug
23

Tuesday update

Not to rub it into my friends and colleagues who are “working” in Orlando this week, but here in Montana it is 73, dry, sunny, and the mountain views are spectacular. Of course, flying into Bozeman isn’t nearly as…challenging as the obstacle course of strollers, elderly folks (my mom is 95, so don’t flame me), clueless travelers, little-kids-running-in-circles and mouse-hat-wearing families that is MCO.

While the attendees at the Montana Governor’s Conference on Workers’ Compensation won’t be partying to ThirdEyeBlind, these westerners have just as much fun at their annual confab as anyone.  Some have even more.  Film at 11.

I’m sure Bob Wilson will report back after his keynote talk here tomorrow; in what might well be a preview of the Clinton:Trump debate the esteemed WorkCompKing and I will be on the stage discussing matters of great import.  As we are the last session before the cocktail hour, don’t expect us to run long.

On to more serious matters.  And not much is more serious than the goings-on in California these days.

In California, we’ve learned that a big chunk of the liens filed are the work of individuals convicted or criminally indicted.  A total of $600 million in liens fall into this category, with a total of $2.5 billion – yes, that’s with a “B” – filed by “68 businesses comprising the top one percent of lien filers [who] filed more than 273,000 liens totaling $2.5 billion in accounts receivable on adjudicated cases between 2013 and 2015.” 

The Department of Industrial Relations’ summary goes on to note:

The assignment of liens by service providers to those who file and collect on liens are, in essence, the buying and selling of injured workers’ treatments and fertile ground for presenting fraudulent claims.  DIR’s review of filing dates indicates that lien claimants tend to wait until after the primary case is settled rather than seeking early resolution of medical necessity.

My interpretation – these scam artists are waiting to file until AFTER the claim is settled because they know full well the fiduciary just wants the damn thing to go away, doesn’t have the resources to fight each and every lien, and is better off paying off these crooks than fighting them.

These people add no value, deliver no service, help no one, and want to get paid for it.  

Here’s hoping California’s legislature jumps on this issue, prohibits lien filing by criminals and for denied claims.  Time is short…

Staying west for a minute, the fine folk at CWCI (Stacy Jones in specific) just published their evaluation of medical fees post-reform.  A main takeaway:

The amount of the reductions [below pre-reform utilization levels] varied by the type of care, ranging from 11.4% for radiology services to 49.5% for medicine services (comprised primarily of ancillary services such as cardiovascular, nerve and muscle testing, and psychiatric testing and psychotherapy), with an overall reduction of 17.7% in all medical services. At the same time, changes in total amounts paid under the schedule ranged from a 44.9% reduction in medicine services to a 12.7% increase in physical medicine services, for a net reduction of 14.3% in payments for all services. [emphasis added]

The implication is this – adoption of Medicare’s fee schedule has increased the volume of and reimbursement for cognitive services – talking with patients, rehabbing patients – and a reduction in payments for doing stuff TO patients; MRIs, nerve tests and the like.

This is good.

Thanks to CWCI’s Bob Young for the info and background.

Housekeeping

The systems folks who do all the IT work on ManagedCareMatters updated our WordPress to the latest version last week, which led to a deluge of bounced emails from former subscribers with dead email accounts.  I’ve been ever-so-slowly cleaning up the subscriber list: this is a highly manual process, requires individually deleting a lot of addresses, and I’m absolutely sure I’ve screwed up and deleted addresses I shouldn’t have.

So, sorry about that.

This is going to take a little while, and in the interim I’m not going to be able to post as often as I’d like.  Hope to get this cleared up by the weekend, or I’m stuck sitting in front of a computer while my lovely bride and friends cavort on the lake.

Grrr.


3 thoughts on “Tuesday update”

  1. It’s funny that everyone seems to want to focus on “lien claimants tend to wait until after the primary case is settled rather than seeking early resolution of medical necessity.” and say that means they are Shady/Crooked/Out to Game the System. The reality of the issue is that most insurance companies will not deal with a lien claimant(legitimate or not) until the case settles. It is an automatic out for those involved in the payer side, regardless of whether the issue is medical necessity or misapplication of the fee schedule, rates under a contract, etc. It is a blanket denial that is supported by the judicial system that does not even allow a provider to officially become party to the case until the case in chief has settled. Believe me when I say that providers are the red-headed stepchild in the industry. Additionally, lien claimants are restricted by date of service to filing liens in California, so they can’t always wait until the case settles or they will be ineligible to collect on those bills. Also, they are required to pay $100 just to file the lien. Any prudent business would wait as long as possible before shelling out money that they may not see a return on for years.

    That being said, certainly with the top 68 providers filing about 1000 liens each per year(the original source I read indicated these liens were filed between 2011 and 2015), this certainly indicates there are some questionable characters operating out there that put a blemish on legitimate providers trying to do something right

    1. Yes and no. It’s true that many adjusters in CA defer liens till the case-in-chief is resolved (to use the CA lingo) and I agree they shouldn’t necessarily do that.

      That said, I also agree the lien process is dysfunctional and is a breeding ground for fraud– and quite frankly, that’s why they often get treated the way they do. As you know, there have been a lot of high-profile fraud arrests in recent years. A lot of collection agencies have outsourced their call centers overseas, so adjusters often get bombarded with calls from aggressive but poorly-trained collection reps. (These are not outliers either. CA WC adjusters deal with this issue on a daily basis.)

      CA has already put in a lot of reforms to address that issue; some of them have worked, but others not so much. A lot of the disputes you mentioned should not be handled through the lien process at all, and CA law is clear on this point. Disputes of medical necessity are supposed to be resolved through Independent Medical Review. Disputes under the fee schedule are supposed to be resolved through Independent Bill Review. Most network contracts have dispute-resolution clauses to be used if there’s an issue involving contract rates; and if the contract is silent on the issue, it’s subject to IBR.

      The bottom line is that I agree with the underlying thrust of this article. Liens in CA need to be brought down to a minimum, if not eliminated completely. The lien process isn’t fair to anyone. It causes legitimate bills to go unpaid, while frivolous bills do get paid. Meanwhile, adjusters (and courts) are forced to spend a huge amount of time and resources on resolving them, when they really should be directing those resources toward helping injured workers.

      There is a better way!

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Joe Paduda is the principal of Health Strategy Associates

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