CA OMFS Reimbursement Reductions

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

To pressure a provider into signing a discount reimbursement contract, Medical Provider Networks (MPNs) can threaten to exclude a provider from the MPN, if the provider refuses to accept PPO or other network 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 then use the discount contract to reduce the provider's reimbursements for countless payers, even those not affiliated with the MPN.

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

These 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. This data represents:

Note that the data does not include procedures where the payer entirely denied payment for the procedure ($0 reimbursement).

DaisyBill updates this data daily.

$138,567,716
OMFS Reimbursement Due
$113,843,581
Amount Paid
$24,724,134
OMFS Balance Due
82%
OMFS % Paid


144
Claims Administrator Count

For each claims administrator payer, this summary calculates the total balance due per OMFS rates, based on the reimbursement amounts the payer actually remitted.

1,756
Rendering Provider Count

For each DaisyBill provider, this data summary calculates the total balance due per OMFS rates, based on the reimbursement amounts the payers actually remitted.

1,672
Services Rendered Count

For each procedure code, this data summary calculates the total balance due per OMFS rates, based on the reimbursement amounts the payers actually remitted.

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 compliant electronic EOR ($0 reimbursements are excluded from data).

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