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CA OMFS Reimbursement Reductions

California’s Official Medical Fee Schedule (OMFS) establishes reimbursement rates for medical treatment furnished to injured workers. However, discount contracting entities known as Preferred Provider Organizations (PPOs) can drastically reduce provider reimbursements, to well below OMFS rates.

To pressure a provider into signing a PPO discount contract, Medical Provider Networks (MPNs) can threaten to exclude a provider from the MPN, if the provider refuses to accept PPO reimbursement discounts.

Once the provider signs the discount contract, the PPO often quietly sells or leases the discounted rates to other PPO entities, and to the many bill review vendors hired by payers. These bill review vendors also use the PPO discount contract to reduce the provider's reimbursements for countless payers that are not affiliated with the MPN.

As a result, payers all too frequently issue Explanations of Review (EOR) that indicate the application of a PPO contract leased or purchased by the bill review — a contract the provider never actually signed.

These PPO discounts are a revenue management nightmare for providers.

CA OMFS Reimbursement Reductions

In California, when a provider submits a workers’ comp bill electronically, state regulations require the claims administrator to electronically send the provider an EOR disclosing payment information as required by the California Division of Workers’ Comp (DWC).

Below, DaisyBill compiles the EOR data that claims administrators electronically send to DaisyBill providers for dates of service on or after Jan 1, 2021. The data represents each procedure where the payer failed to reimburse the provider 100% of the OMFS rates. Note that the data does not include procedures where the payer entirely denied payment for the procedure ($0 reimbursement).

DaisyBill updates this data daily.

$89,855,692
OMFS Reimbursement Due
$71,153,735
Amount Paid
$18,701,956
OMFS Balance Due
79%
OMFS % Paid


137
Claims Administrator Count

For each claims administrator payer, this summary calculates the total reduced OMFS Balance Due that the payer failed to reimburse to providers who treat California injured workers.

1,408
Rendering Provider Count

For each DaisyBill provider, this data summary calculates the total reduced OMFS Balance Due that the claims administrator payer failed to reimburse the provider for treating California injured workers. 

1,477
Services Rendered Count

For each procedure code, this data summary calculates the total reduced OMFS Balance Due that claims administrator payers failed to reimburse providers who treat California injured workers.

5
Fee Schedule Count

The California Official Medical Fee Schedule (OMFS) consists of 7 separate fee schedules. DaisyBill providers submit bills for 5 of these fee schedules (DaisyBill does not support bills for inpatient hospital and ambulance services).

While DaisyBill providers submit bills for Medical-Legal Evaluations and Copy Services, the DWC does not include the reimbursement rates for these services in the OMFS. Instead, the DWC maintains separate fee schedules for these services.

DaisyBill Reimbursement Data Explained

The data reported on this webpage is for all dates of service on or after January 1, 2021, where the payer remitted a reduced reimbursement for the procedure ($0 reimbursements are excluded from data)

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