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Florianman kleinman

Insurance Defense at statue of liberty
Phone 8053878605 ext 2
Email flofloflo@floflo.com
Website -
Address 123 moliere avenue
thousand oaks
CA, 91360

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Applicants' Attorneys Alarmed by Incentive Program for MPNs

By Sherri Okamoto (Legal Reporter)

Monday, March 28, 2016 | 5610 | 17 | 23 min read

California applicants' attorneys say they are outraged with the news that some medical provider networks are using economic profiling to determine the top-performing doctors within their networks, and at least one is promising to reward the best performers with extra compensation. The Labor Code expressly allows MPNs to do economic profiling and to offer incentive programs based on doctor performance as long as the plan administrator files a description of the program policies and procedures with the Division of Workers' Compensation. The Harbor Health S...

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Satish Kadaba Nov 3, 2016 07:58 AM

with SB 863 and the MPN incentives, being an IW in CA is wrought with lies and deceit. All other ins companies incl Medicare/Medical should wake up as care for an IW is being shifted to the private arena and the W/C ins companies continue to reap profits. The cost od medical care has been superseeded by adm costs that ins com have to deny treatment.The CA medical license is not based on care controlled incentive but by proper medical care, apprpropriate compassion and consistent with the care given to the community at large.

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John Hill Nov 3, 2016 07:58 AM

Sorry to inform you......but what you see in WC is what is now in full implementation mode in Obama Care. Get ready...because a brave new world is upon us!

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Jason Bernard Nov 3, 2016 07:58 AM

It is absolutely ridiculous that Harbor will only compensate at 100% of OMFS if physicians basically don't do surgery, don't order MRI, no meds and limit physical therapy to 6 visits. Anything outside of this regiment the physician gets less than OMFS. This comp system has already been flushed down the toilet. Now we are moving quickly going down the sewer to be dumped in a waste pool somewhere. OMFS is a set a price points to be paid for performing a service. Not more, not less. I don't agree that carriers could/should be able to pay less at their own discretion or simply because they don't like a physicians profile. The only other place in the world I have seen this done are third world countries when bargaining for a better price on a belt from s street vendor. I hate economic profiling. I hate SB863. I hate MPN. I hate the bozos that created this law. And I really hate the people that defend it as "working." It's not working. Same amount of liens this year as years past. Same amount of IMR because there is the same amount of blanket denials coming from the same carriers that don't authorize anything; because some person that never sees the injured worker says a MRI isn't medically necessary because the X-ray is normal. What?!?!?!?! My knee X-ray is normal all day long, yet MRI reveals a torn ACL. Moron. And you're stuck with that decision for a year. And I get paid less than fee schedule.

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John De Vasure Nov 3, 2016 07:58 AM

Are we the only ones concerned? As a TPA, we deal with attorney selected MPN physicians. Many of these MPN physicians even address their progress reports to the attorney with a CC to us, the TPA.

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Joe Lamp Nov 3, 2016 07:58 AM

Financial "incentives" of ANY kind, the ability to terminate a physician's enrollment in a particular MPN, are all incentives to influence a physician's decisions. READ the labor code. Where is the fine line between "Incentives" and bribes? If the physician plays nice with the insurance carrier, he'll get paid more.... This isn't general insurance healthcare...this is medical intervention pursuant to a claim for benefits. Wake up California.

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Corey Slagle Nov 3, 2016 07:58 AM

I agree that the insurance company should not be allowed to incentivize doctors, but when I read CAAA's response I laughed. "They're supposed to be paid to practice medicine, not to improve the numbers of an insurance company's bottom line," he said. Insert applicant attorney law firm name in for the insurance company in the previous sentence. That's been going on for decades.

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John Kamin Nov 3, 2016 07:58 AM

Or as we saw in the SCIF flap a few months ago, this could be the MPNs' way of identifying which PTPs are billing every single medical report as a med-legal when the OMFS obviously bars them from doing that.

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Joy Scott Nov 3, 2016 07:58 AM

On behalf of Harbor Health Systems: We understand that applicant attorneys may have misunderstood the economic profiling model utilized by Harbor. Not only is there no connection to whether a doctor reduces the amount a care delivered to an injured workers, the model works quite the opposite from the concern expressed. A provider who delivers better health outcomes can in fact spend more on care than their peers and actually score in the top 20% of the benchmarking. This is because our model focuses on total outcomes; cost is only one of several factors measured and it is measured in the aggregate with medical spend, indemnity spend, and claims expense. A doctor can actually drive higher spend in medical if that investment results in better cure rates, reduced lost time, and reduced litigation. It has long been the position of Harbor that top doctors cure patients better, and that cure drives total claims savings by avoiding the need for significant recovery time, second and third procedures, or complications where certain conditions worsen when the patient doesn't get what they need timely. We have over a decade of data that shows in cases of the best doctors, they are not typically the least expensive doctors when viewed solely on medical costs. When you deliver all the care needed to cure a patient, good things happen for the patient, the employer, and the payer. Our profiling focuses on all the factors that indicate whether a patient was effectively and efficiently cured, whether they achieved a sustainable cure, and, when the patient is taken off work, whether they attain a sustainable level of function to return to work in a timely manner. These factors drive the metrics used to scorecard doctors more than anything else, and a doctor who does not get the patient what they need when they need it is unlikely to do well in the more important outcomes.

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Randy Bugg Nov 3, 2016 07:58 AM

Notice the outrage geared toward, "will my client get a lower rating?" = "will my fee be affected?" Rather, shouldn't the interest be whether the treatment was effective in returning my client back to work or preinjury status??? Or even, is this a provider who overbills, overprescribes or frequently requests treatment outside of MTUS, ODG or ACOEM?

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Pete Thomas Nov 3, 2016 07:58 AM

Boy are you living in a Fantacy world I was kicked out of an MPN for seeing a patient because the claim was denied. These ins carriers threaten doctors every day and in many different ways. For instance if you try and dispense meds out of your office certain carriers will remove you from the MPN. If you want to see a patient on a lien basis you can be removed from the MPN. This is nothing more then extortion and the carriers should be sued for this .

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Jerry Wells Nov 3, 2016 07:58 AM

The shock we hear expressed at performance incentives ignores the fact that most health plans these days--for non-industrial treatment--include performance evaluations of their doctors. Why should it be any different in Comp?

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Dr. Robert Weinmann Nov 3, 2016 07:58 AM

I wrote, in The Congressional Record, 9 September 1998, and the San Francisco Examiner, 12 Jan 1996, that it was recognized that "economic credentials for physicians ... could be disastrous to patients." It was made clear that "patients need to know that before they join any managed care plan they must make sure the plan manages to take care of them before it takes care of its owners." It was pointed out that "in some plans, doctors operate under 'gag' or 'no-cause" clauses whereby "a doctor's criticism of a plan's refusal to provide diagnostic testing or recommended treatment may be treated as corporate disloyalty and grounds for dismissal." These sentiments are as true about MPNs as about HMOs. This hypocritical corporate approach to denial of indicated medical care, recognized at the highest levels in 1996, expanded over the next 20 years because it makes money. Robert L. Weinmann, MD, Editor, The Weinmann Report, www.politicsofhealthcare.com

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Mary Huckabaa Nov 3, 2016 07:58 AM

"Diane Worley, the director of policy implementation for the California Applicants' Attorneys Association, said the group opposes the idea of "bonuses being paid to MPN doctors to deny care to injured workers."" I agree....but let's be clear, the MPN doctors are not bein paid to deny care, they are being paid on a sliding scale based on the outcome of the treatment they prescribe, the lower admin costs for staying in MTUS guidelines, and the recovery of their patients. "He said he plans to start asking doctors "are you making money by giving my client a lower disability rating?""..... OH, because you don't choose your client's doctors based on their history of giving HIGHER disability ratings? That's what AME/QME are for. I hope that's not all Garvey has to say, because that sure sounds like the ONLY thing he cares about his HIGHER PD. We are all looking for lower PD, better outcomes, better recovery from injury and return to work. I agree with Jacobsmeyer on this one.

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Barb Robinette Nov 3, 2016 07:58 AM

References to Coventry in this article were not made in concert with individuals within the Coventry organization. The linked document was not current as it spoke to our process being in the preliminary stages. Coventry has an MPN compliant profiling process in place for purely educational purposes. It is not used for Utilization Review; Peer Review; any provider incentives and penalties; provider retention and/or termination decisions.

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Jan Richmond Nov 3, 2016 07:58 AM

Well John...if your employers had a decent MPn with good doctors to who, they sent IW in the first place, AA wouldn't have to find another doctor. The majority of the really efficient good doc's are now "by referral only" which I question as legit and the majority of AAs know who is good and who is not in terms of intelligence and treatment in the medical community.

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Jan Richmond Nov 3, 2016 07:58 AM

Well John...if your employers had a decent MPn with good doctors to who, they sent IW in the first place, AA wouldn't have to find another doctor. The majority of the really efficient good doc's are now "by referral only" which I question as legit and the majority of AAs know who is good and who is not in terms of intelligence and treatment in the medical community.

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