CASA Says New Workers’ Comp Fee Schedule Will Hinder Access to Needed Surgery for Calif. Injured Workers

September 17, 2003

The California Ambulatory Surgery Association (CASA) stated on Tuesday that access to surgery for injured workers in California will be dramatically reduced under the outpatient fee schedule approved by the California legislature.

Common work related injuries requiring surgical procedures such as knee or shoulder arthroscopy, carpal tunnel release and hernia repair will reportedly be denied injured workers because the mandated reimbursement rates would be less than the cost of performing the procedure. The fee schedule is 15 percent below the minimum amount needed to cover the cost of surgery according to the independent research group retained by the State of California.

“Facilities will stop performing workers’ compensation surgeries if the fees do not cover the cost and injured workers will be denied care,” said Tom Wilson, president of CASA.

The new fee schedule is reportedly so low; the cost of surgical implants alone for some knee repair surgeries is greater than the proposed reimbursement rate. Unless changed, this new law will cause a serious disruption in providing timely, quality care to injured workers in California. In fact, after careful review and study, the states of Oregon and Washington reportedly both set outpatient fee schedules at about 250 percent of Medicare Groupers, which for many procedures is far above the 120 percent proposal in California, and their systems have been working exceptionally well. California State Compensation Insurance Fund (SCIF) pays outpatient centers about 200 percent of Medicare Groupers, and they are reportedly considered the low-reimburser in the state.

According to CASA, the final legislation adopts an unrealistically low fee schedule and actually extends the payment period for insurance companies from eight weeks to nine weeks.

It also permits insurance companies to dispute any and all claims by asking for an audit which can extend the payment period to six months or longer, even though nearly all worker’s compensation surgeries require authorization from insurance companies prior to surgery. One of the objectives of a mandated fee schedule is to eliminate fee disputes and promote prompt payment. In comparison Medicare, under a mandated fee schedule routinely reimburses facilities in less than 14 days.

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