SB 863: Workers’ Comp Cases In Many Areas Will Not Be Able To Adhere To A Fee Schedule For Home Health Services.
By Lonce LaMon - February 19, 2013
Now that SB 863 is about to impose a fee schedule, there is a rising concern over home health clinician availability and the service fees (especially for registered nurses) for workers’ compensation cases in California. Many service providers are anxious since this is the first time a fee schedule will be in place for these services and with a serious shortage of registered nurses (even physical therapists and medical social workers) in rural areas outside the major metroplexes, securing these clinicians to service workers’ compensation cases in these areas outside major cities will become not only more difficult, but even impossible with a fee schedule.
The difficulty agencies have in finding nurses in these rural areas now is so great that to further have to stick to a fee schedule based upon a state average rate boggles their minds. The most drastic shortages of clinicians are in the mid-section of the state—between Bakersfield and Sacramento. There’s also a hole between San Jose and Santa Barbara, plus a dearth of all clinicians in the area east to the Nevada state line from San Bernardino.
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With only a handful of agencies that service these rural areas, many workers’ compensation home health providers feel Legislators need to look deeper into this issue before moving forward. Some agencies in these areas of greatest shortage won’t even accept workers’ compensation cases. Then combine that factor with an ever growing population of elderly that are cash paying clients and you have a real dilemma for workers’ compensation patients. This problem is here already without any structured fee schedule.
Providers have had to beg in the areas where there is only one agency. The agency argues that it’s bone tired of getting both short paid and late paid on work comp cases and would rather take on cash patients that pay in full and on time.
Work comp service providers now fear the injured worker will suffer in these regions and might even have to go back to the hospital or skilled nursing facility if the fee schedule is too low. If claimants have to remain in the hospital or go to skilled nursing facilities because no clinicians are available at the fee schedule rates to work in the home, then all the savings that was hoped for with the implementation of a fee schedule will go out the window.
One service provider professional put it this way: if there was a shortage on bananas and you went to the grocery store, got to the check-out line with your bunch of bananas and told the clerk you would only be paying the fee schedule price for the bananas, there’s a good chance he’d tell you the guy behind you is willing to pay double so I’m sorry but we’d rather sell to him.
The agencies in the rural areas have to work so much harder to find clinicians for workers’ comp cases and it’s this high difficulty factor that drives up the rates. They have to charge enough to survive. Therefore, some fairly high rates will have to be charged to the workers’ compensation carriers, however even with these higher rates it will be substantially less costly than keeping claimants in the hospital or transferring them to skilled nursing facilities.
This writer, coming from an agency background, knows how hard searches are when there’s a very low supply and availability of a particular skilled professional in an area. When searches take enormous quantities of time and man power, it costs more. Sometimes professionals even have to temporarily be relocated from substantial distances. Time is money. Relocation is money, too.
Yet, educating the claims adjuster about this problem is a good place to start in order that post-surgical patients don’t remain in the hospital or a skilled nursing facility at five to ten times the cost because no nurse can be found at a fee schedule price.
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If management erroneously thinks it has to insist upon adherence to the fee schedule, it will not be seeing the forest for the trees. |
Paying more for in-the-home nurses and other clinicians in the remote areas is still a big cost savings over keeping the claimant in the hospital or a skilled nursing facility.
Amongst the Labor Code amendments that SB 863 provides there’s a line about 400 lines below the Section 74 and under Section 5307.1 that reads: This section does not prohibit an employer or insurer from contracting with a medical provider for reimbursement rates different from those prescribed in the official medical fee schedule.
Jorge Alexandria, a veteran claims supervisor experienced in workers’ compensation in Southern California, wrote, “Of course, nothing will prohibit inexperienced and unsympathetic claims adjusters from declining to pay higher than the fee schedule allows; they think that they are saving their insurer money when in fact the denial and increased hospital stay actually increases the expense of the claim.”
Thus, the claims adjuster’s hands won’t exactly be tied to the fee schedule, but it complicates and adds to the learning curve. If management erroneously thinks it has to insist upon adherence to the fee schedule, it will not be seeing the forest for the trees. Then this whole cost savings scheme intended by a fee schedule to contain spiraling medical costs and curb fraud will turn out to be one big fantasy.
lonce@adjuster.com
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