Workers’ Compensation Reimbursement in 2019

California Providers: have you noticed a change in reimbursement for your Workers’ Compensation claims? 2019 brought changes to the reimbursement formula for the Official Medical Fee Schedule (OMFS), which was already complicated enough to navigate for providers.

The Change

The California Division of Workers’ Compensation (DWC) has altered their reimbursement formula so it now adjusts for your region. In prior years, the reimbursement was consistent state-wide using the Average Statewide Geographic Adjustment Factor (GAF). They are now accounting for your region with what is called the Geographic Practice Cost Index (GPCI). You can find your GPCI here.

The nitty gritty of it means their calculation went from:

[(Work RVU * Statewide Work GAF) +(Non-Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee

To:

[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF) = Base Maximum Fee

What it Means in Practice

Because staring at a formula may not give you the information you need in practice, what you need to know is:

  • Most regions in California will actually see a decrease in Workers’ Compensation reimbursement with the introduction of GPCI; as much as a 4% reduction. Examples of these regions: Modesto, Bakersfield, Fresno, San Diego.
  • Regions with a higher GPCI can expect an increase of 8-10%. Examples of these regions: Alameda and Contra Costa County, Santa Clara County, San Francisco and San Mateo County.
  • GPCI does not affect most of the codes exclusive to Workers’ Compensation (outside of CPT) such as your codes for Primary Treating Physicians Report – PR-2 – billed as WC002. Those codes are set yearly, and are paid the same fee statewide. You can find these rates in the official text of regulations, pages 56-57.

To ensure you are being paid properly, adjust your current method of calculation to remove the GAF and replace them with your specific GPCI. If you currently have no method of calculating your expected Workers’ Comp reimbursement, don’t worry, you are likely in the majority. You can set up a spreadsheet using the formula above, and the factors for the formula are published for each CPT code. If you need clarification on the factors that go into the formula you can always take a look at the text of regulations from the DWC.

Need More Help?

We absolutely understand that the technical information given above can feel overwhelming. We exist to help you! Contact In Charge Office Solutions below to see how our services can relieve your administrative headaches. You can also always give us a call at (925)398-8635.

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