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Tuesday, May 19, 2015

Attorneys Argue whether SCIF Letter Shows MPN 'Bullying' Doctor or 'Self-Policing' Billing Rules

  • By Sherri Okamoto
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  0 shares
State Compensation Insurance Fund's May 11 letter to a doctor within its medical provider networ…

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Anonymous Nov 3, 2016 a 2:58 pm PDT

Defense guys- good try, but Alan is right. The MPN idea was reasonable, but as usual has been misguided. The state of WC treatment today is frightening. If you are a doc not in the MPN, you will not be paid for treatment. If you file a lien, it will cost $150 and you will wait years and there is a good chance you will lose. Most doctors cannot hold out. If you are a large chiro group who specializes in denied cases, you may have a 4-5 year collection cycle and can survive. If you are a board certified MD trying to make a living, you must be in MPNs today. I am sorry to report that they will kick you out without warning. All of us have had these bullying letters and we now know that they are our masters. Applicant attorneys- if we order internal medicine, sleep and psyche willy-nilly, we will be tossed out quickly. Whatever they perceive that costs them money, is a reason for termination. They talk in terms of outcomes, MTUS as the bible. It is code that you are costing them too much. Put a patient TTD, watch it. They want that patient back to work in pain, but with work restrictions. If you don't- you are out.
Do not ever think of treating denied body parts or you are out. If you treat denied cases, you are not the kind of doctor they want and the next day your name has disappeared from the MPN website. There is no appeal. They can have whomever they want in their MPN. Is this fair? It is reality and we must live with it. And if you do their bidding, they will reward you with reduced fees, no record review and minimal report fees and $11.90 for a PR2. Welcome to Ca WC 2015

Anonymous Nov 3, 2016 a 2:58 pm PDT

Doesn't surprise me at all. They tell the docs how to treat. They tell UR what to approve and what to deny. Isn't that how Comp is supposed to work?? This will never change. The biggest thieves in the business are SCIF and the DIR. I don't see anything changing until the two of them are controlled.

John Kamin Nov 3, 2016 a 2:58 pm PDT

"They're being told if you want to stay in MPN, don't bill for med-legal when it is clearly not a med-legal report," Gurvey opined.

There we go, fixed that for ya.

The report was clearly not a med-legal report, yet they're billing it as one. This happens all the time, and it's intentional overbilling by the doctor's office. Then when SCIF calls them on it, the doctor is suddenly unavailable, as if he or she is not just a hallway away from the secretary.

Cliff Bernstein Nov 3, 2016 a 2:58 pm PDT

Forget about getting kicked out of the MPN, what about the lying and cheating that goes on preventing doctors from getting into the MPN's even when they have no doctors in that specialty that will actually treat w/c patients. I have had plenty of occasions that I can't get in an MPN that has no other MD options available within 100 miles. We are given bogus lists of doctors that are not practicing anymore, won't see w/c patients, or is a entire list of Kaiser or Health works MD's. The whole MPN process is one of the most unethical things the carries use to cheat patients out of care. Imagine forced to do surgery in a facility that doesn't know what they are doing? How safe is that

Anonymous Nov 3, 2016 a 2:58 pm PDT

As you all know, none of this would have happened if the doctors and lawyers would have played fairly. In 1992. A multi-specialty (applicant) clinic averaged about $4,000-$5,000 a case. By 2002 we were averaging $20,000 a case. Do the math.

Charles Cleveland Nov 3, 2016 a 2:58 pm PDT

You're citing stats from 1992 and 2002? SB 899 decimated those numbers in 2005, over 10 years ago so your math is a little outdated. Injured workers and medical providers are trying to deal with current problems. Not only are doctors bullied by the insurance companies but they often have to pay a mandatory percentage (kickback) to a middle management company just to be in the medical provider network. There is no real or viable grievance process for doctors kicked out of networks and the insurance companies have too much control over medical provider networks. Here some new math, looks like algebra: MPN+UR+IMR= 90% TX denials

Mary Huckabaa Nov 3, 2016 a 2:58 pm PDT

I'm really replying to CRCattorney: Where do you get 90% treatment denials? Must we really do this math again?

Anonymous Nov 21, 2016 a 6:49 pm PST

Frustrated, those of us on the applicant side are not seeing the 95% approval rate. Can you list 20 pain management doctors or orthos surgeons in Orange County, or Inland Empire, or even LA county who are receiving 95% approvals on their UR request? If you can list 20 doctors( and they cannot work in an industrial clinic) I may reconsider. I have yet to find any doctor who is seeing this. I have not seen one doctor on this site post in favor of IMR, stating they receive a 95% approval rate on requests. Why do you think that is since this number is so high?

Anonymous Nov 21, 2016 a 6:49 pm PST

Would the Patterson vs Oak Farms case work in a situation in which medications were unilaterally denied, when the injured worker had not had a change of condition?

Why are medications being run through UR monthly, when there has not been a change of the injured workers condition?

Also, if the claims adjuster did not send relevant records to UR, which resulted in a denial could the doctor request another UR even after there can been a IMR denial?

Mary Huckabaa Nov 3, 2016 a 2:58 pm PDT

Given that some Rx require physician to see the patient on a regular basis to determine if the medication is still necessary, unless it is a 90 day Rx with 3 refills....once the refills are done, it should go back to UR. If the adjuster did not send relevant records to UR, file the IMR and submit the relevant records yourself.

John Hill Nov 3, 2016 a 2:58 pm PDT

Sorry to inform you....but what you see in WC is what is now in full implementation mode in Obama Care.

Get ready...because a brave new world is upon us!

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