Chiropractic Organizations Fight Unjust Fee Schedule

By now every California chiropractic doctor should know that the California Division of Workers' Compensation (DWC) proposed an unreasonably low relative value (RV) for the new chiropractic manipulative treatment codes in the 1998 Official Medical Fee Schedule (OMFS). The DWC is the agency that produces the OMFS for workers' compensation. With the California Chiropractic Association (CCA) taking the lead, the two major California chiropractic organizations, CCA and the International Chiropractors Association of California (ICAC), joined efforts to fight the DWC on this issue and its administrative director, Mr. Casey Young.

Phase one completed: The DWC held hearings Nov. 24-25 to receive comments on the proposed OMFS. CCA representatives Dr. Steven Becker, Dr. Robert Jaramillo and Dr. Craig Little testified on both days.

The Los Angeles College of Chiropractic was represented by its president, Dr. Reed Phillips, and 15 students, all of whom testified on the unfair actions by Mr. Young and the DWC. Many other providers and payers testified in intense and often combative terms.

The oral testimony represented a "preview" of the extensive official written comments CCA submitted. In a two-inch thick document prepared by CCA's legal counsel, containing 18 exhibits, numerous charts and footnotes, legal citations and extensive, comprehensive and hard-hitting legal analysis, CCA analyzed the proposed OMFS and recommended reasonable alternatives. (Read on for a summary of these comments.)

CCA and ICAC also organized massive political campaigns, declaring clearly that the chiropractic profession will not accept discrimination against chiropractic doctors. CCA's political allies, including several key legislators and contacts from the governor's office, wrote and phoned Mr. Young to inquire about the proposed fee schedule. ICAC members contacted their legislators and organized patients to write letters in support of the chiropractic profession.

Phase two in progress: With the November 24-25 hearings completed, Mr. Casey Young must decide whether to change his proposal on the OMFS or send the proposed OMFS "as-is" to the Office of Administrative Law (OAL) for review and approval. (At the time of this writing, it is not known which he will do). If he changes the OMFS to comply with CCA's recommendations (below), the battle is over, and justice wins out. If he sends the OMFS "as-is," then we're in phase three and a whole new ball game. Based on CCA's written comments, the OAL may very well decide during phase two to reject the proposed OMFS, unless and until the administrative director can substantiate his proposal. If the OAL allows the proposed regulation to stand, CCA will explore its options for litigation or other action.

Phase three, the last resort: We hope that the DWC and/or the OAL resolve this before phase three kicks in. If they don't, the CCA leadership is committed to fighting this to the end.

Summary of CCA Arguments CCA submitted over two inches of written analysis, arguments and recommendations concerning the OMFS. Here's a brief summary of CCA's official comments.

The CMT Codes are too low when compared to:

• RBRVS (a nationally accepted system of assigning RVs to procedure codes);
• federal workers' compensation;
• Medicare;
• other states;
• average billings of chiropractors in California;

Accepting Medicode's recommendation for a 3.9 RV is a mistake because:

• No charge data existed for Medicode to justify its RV.
• Medicode admitted its system would produce "aberrations."
• Medicode recommended that OMT and CMT be valued the same, but then recommended a lower value for CMT.
• Medicode's recommendations in Alaska yielded over two times the value as Medicode's recommendation in California.
• Even the IMC didn't accept Medicode's recommendation.

The OMFS discriminates against DCs by:

• Placing CMT in physical medicine and OMT in medicine, subjecting CMT to the cascade, but not OMT.
• Requiring DCs to submit reports for extraspinal manipulation but not DOs or MDs.
• Valuing CMT codes lower than OMT and many non-physician services.

Other issues: utilization review, provider contracts, hot/cold packs, new forms, medical legal fee schedule, clean-up:

CCA's official comments covered all of the problems in the proposed OMFS and other new regulations, not just the CMT codes. In brief, CCA argued on:

Hot/Cold Packs: The administrative director gave no viable rationale for deleting all reimbursement for hot/cold packs.

Utilization Review: The law does not allow workers' compensation insurers to deny reimbursement for medically necessary care to "cure or relieve" simply on the basis that the doctor didn't "pre-authorize" the care. On the other hand, it is acceptable for the insurer to give a written assurance that the insurer is in agreement with the treatment plan and that the insurer will reimburse.

Provider Contracts: The OMFS can't simply "exempt" all agreements between providers and payers from the terms of the OMFS. The potential negative consequences to injured workers are too great, and this decision should be decided by the legislature.

Proposed New Permanent and Stationary Report: The form doesn't cover all of the items that the primary treating physician is required to include.

Medical Legal Fee Schedule: The OMFS should include a $200 value for missed appointments, and an increased conversion factor, as these were recommended by the IMC.

Clean-Up: Numerous typos, inconsistencies, mistakes and other miscellaneous items exist in the proposed OMFS; CCA detailed these one by one and recommended solutions.

Rebecca Berg
CCA Executive Director