Kudos to CorVel

Tuesday, May 28, 2013 | 0

I’ve often had issues with CorVel for their billing practices and other matters, but I’d be remiss if I didn’t applaud the managed-care firm for their willingness to fire a doctor that was allegedly prescribing Wasabi Rub, theramine pills, Gaba-2k rubs and surface EMGs, some of which were allegedly upcoded to needle EMGs – and then refusing to discuss these treatments with peer-review docs.

The incident happened – of course – in California, where CorVel and Dr. Douglas Roger have been in litigation for several years over CorVel’s summary termination of Roger from their workers' comp medical provider network. The court case is somewhat complicated by CorVel’s failure to follow their contractual obligations in terminating Roger, but the court nonetheless upheld the decision. (Decision is here.)

What makes this case so important is it “balances” an earlier case, known as Palm Medical, where State Compensation Insurance Fund refused to admit a provider to its MPN. Ultimately the court found in the provider’s favor, much to the dismay of the insurer and employer communities.

The CorVel v. Roger case gives payers hope that they can terminate a provider who fails to meet the obligations contained in their contract with the payer, obligations which should – and almost always do – include requirements that the provider follow applicable treatment guidelines, respond to requests for consultation with peer-review physicians and otherwise treat appropriately.

That said, CorVel could have lost the case as it did not follow the “three-step” process in terminating Roger.

What does this mean for you?

Word to the wise payer – if you’re asking the providers to follow the contract, probably a good idea if you do too. 

Thanks to WorkCompCentral for the heads’ up.

Joe Paduda is owner of Health Strategy Associates, a Connecticut-based employer consulting firm, and co-owner of CompPharma, a consortium of workers' compensation pharmacy benefit managers. This column was reprinted with his permission from his Managed Care Matters blog.