There’s been a lot going on in New York’s work comp system; heated discussions over adoption of disability and medical treatment guidelines, an uproar over assessments for self insured groups, and ongoing actions and attempted actions regarding the pharmacy fee schedule have kept our attention focused on the Empire State for lo, these many months.
Now comes news that New York may be the first state to dramatically increase payment for cognitive services. I heard this from WorkCompCentral’s Mike Whitely, who informed me that New York Work Comp Board Chair Bob Beloton is looking to raise reimbursement for physician evaluation and management codes by 30%.
Mike will have much more on this tomorrow (read WCC to see); I’ll focus my comments on the whys and wherefores.
First off, this is a good move, for many reasons. Fees haven’t been increased for 14 years in New York, making it high time for a raise.
Second, if there’s one service that is waaay under-valued in work comp, it is the time the treating physician spends with the injured worker, discussing the injury and treatment options, providing insights into medical care under work comp, educating the worker and their family about return to work, and discussing same with the employer and insurer. A 30% increase is money well spent.
Third, this will hopefully draw the attention of other states, and get them thinking about the significance of cognitive services.
All that said, I do have a major concern – as should you. About half of the care delivered to work comp claimants in NY is thru a discounted network. These networks may well try to keep their current discount arrangement, as a higher fee schedule will mean they deliver more ‘savings’ and thus earn higher fees (they get paid on a percentage of the ‘savings’, or the delta beween the fee schedule and contracted reimbursement amount).
It will be too bad if this (possible) increase doesn’t result in actual increases in reimbursement, and instead just makes networks more profitable.
What does this mean for you?
Good news.
Sep
1
Of real interest in NY is the physical medicine component of the WC fee schedule. These codes apply mostly for PT/OT services. There is an arbitrary cap on what can be billed per visit. Basically there is an 8 RVU cap per regular visit – which translates into 2 procedure codes (i.e. one therapeutic exercise = 3.97 RVUs and one manual therapy code = 4.23 RVUs; total for the 2 codes = 8.2) which is then reduced to 8.0. In essence we are paid to provide in most cases less than 2 CPT codes per visit when the national average for a PT visit is at or about 4 codes/visit (close to 16 RVU’s). In essence the NY WCB only pays for a half a visit. I am sure that if a medication was prescribed by an MD and the pharmacist was only paid for half the dosage prescribed there would be a real issue. PT’s unfortunately have chosen to just shorten the time with a patient and now seen as over utilizers. That is why we are at 22 visits/year and the 16 state WCRI average is 13. When you pay 1/2 of Medicare you will get more utilization. What they fail to realize is that translates into a lot more indemnity which costs more than the therapy would at Medicare rates.