In the world of workers’ compensation, healthcare professionals’ jobs are not limited to providing medical care. Going back and forth with the administrator to get the bills paid is an additional task. Since DWC California has very few guidelines that ensure a medical provider’s payment for the services they have offered, expert negotiators like MLM often have to take over this hassle from our client’s hands.
In a recent Marquez, Gonzalo Vs. Edwin Allen Adams’s case, lack of professionalism, delayed response, and suggestions to settle at a nominal amount weren’t the only issues. The real problem was that the Third-Party Administrator (TPA) responded by claiming the treatment was non-certified due to exceeding the 24-visit cap.
After going back and forth, MLM was able to negotiate a reasonable settlement. Our expert negotiators clearly stated that the 24 cap was not an issue here. At the initial stage, a PTP creates a treatment plan for 1-2 weeks and re-evaluates after the set period to check if the prescribed treatments have an impact on patients or injury. Medical providers need to issue a PR2 report that analyzes the overall progress of the given treatment based on which future treatments will be given.
In case of an improvement in the services or not, the treatments are continued or altered. Based on the PR-2 report on the case, which is a status report that details any permanent, stationary, or future medical issues that might arise due to an accident incurred at work, we negotiated our provider’s services to be valid since the 24-cap not apply to treatment from an MD. The QME evaluation found all our treatments reasonable and medically necessary; they did not object to the treatment, saying that a chiro cap should have been applied. We suggested the in-house filing of the case to save time and resources for all the involved parties.
Being experienced in workers comp negotiations, MLM settled the said lien in-house for $30,000 based on the OMFS value of the said treatment. Our expert team of negotiators maintains professionalism in their encounters and ensures swift transactions for our clients.
Wasting time on negotiations with administrators is not something medical providers need to worry about. MLM makes sure we handle everything from RFA filing to prompt payment for our clients so they can focus on improving their healthcare practice.
