Blog: Daisy News

News, data, & insights about workers' comp billing

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  • May 23, 2018

    IMR Unlikely to Overturn UR Decisions

    When a payor’s utilization review organization (URO) denies treatment recommended by an injured worker’s treating physician, the only recourse is for the injured worker to appeal the denial to Independent Medical Review (IMR), administered by Maximus Federal Services.

    A recent analysis of Maximus’ IMR decisions by California Workers’ Compensation Institute (CWCI) found that Maximus upheld the overwhelming majority of payors’ utilization review decisions.

    The notion of IMR as a largely futile pursuit works to the advantage of the CWCI, an insurers’ and employers’ group with the stated aim of analyzing data “to improve benefit delivery.”

     

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  • May 18, 2018

    IBR vs Lien: Coding Disputes

    When the required Second Review appeal process fails to produce correct reimbursement, it's important for providers to understand the correct next step in the appeal process.

    With the passage of SB 863 (effective 1/1/2013), California law requires Independent Bill Review (IBR) “if the provider disputes the amount of payment made by the claims administrator.” To the extent the dispute is not about the amount of reimbursement, a provider may file a lien to contest incorrect bill payment.

    Generally, liens are reserved for matters of liability and legal duty. Sometimes, though, a provider may not be sure which option applies. For example, some argue that disputes over correct coding should be resolved by a lien rather than IBR.

    However, recent lien cases indicate that liens regarding coding disputes will be dismissed — at a potentially significant cost to the provider.

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  • May 17, 2018

    No Response? What to Do When Claims Admin Ignores Your Bill

    It happens far too often: providers treat an injured worker for a California employer, send the bill to the claims administrator, and then...nothing.

    Workers’ comp is frustrating enough, but few things are more irritating than hearing crickets in response to a compliant original bill. Fortunately, California law offers remedies. Here’s how to obtain reimbursement (and address blatant non-compliance) when the claims administrator fails to respond to your bill.

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  • May 16, 2018

    FYI: Workers’ Comp Telemedicine Reimbursed at Facility Rates

    In California and elsewhere, telemedicine isn’t just the future — it’s the present. Of course, this shift to increasingly virtual services means unique new wrinkles in the workers’ comp billing and payment process.

    One common point of confusion is “where” telemedicine takes place for billing purposes; i.e. in a facility or non-facility. Fortunately, the Official Medical Fee Schedule (OMFS) provides a simple answer: place of service code 02.

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  • May 11, 2018

    Discount Dangers: The Provider’s Bill of Rights (Rights VI and VII)

     

    Discount Dangers is a DaisyBill series on the ways discount contracts unscrupulously lower work comp providers’ reimbursements. With this series, we shine a light on the worst practices and help providers fight back.

    Eligibility and active encouragement: These two principles uphold the equitability of discount contracts. Providers have the right to know who’s applying a given discount to which bills, and to have patients steered to their office in exchange for those discounts.

    Over and over, Labor Code Section 4609 mandates adherence to these dual precepts. The next two Provider’s Rights in this series further clarify exactly how eligibility and active encouragement are supported by law.

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  • May 9, 2018

    Medical-Legal Complexity Factors: Provider Requirements

    Recently, a DaisyBill client faced unreasonable demands from a bill review regarding complexity factors for medical-legal billing code ML104. Fortunately, our client’s refusal to accept arbitrary requirements ultimately won out — proof that providers can succeed when empowered with knowledge of the rules.

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  • May 8, 2018

    Medical-Legal: When to Bill For Report Preparation

     

    Medical-legal billing is a special kind of tricky.

    This unique subset of California workers’ comp has its own rules, its own fee schedule, and its own complications. Among those complications is how and when to bill for time spent preparing medical-legal evaluation reports.

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  • May 4, 2018

    Medical-Legal Fee Schedule: DWC Proposes New Amendments

    The California Division of Workers’ Compensation (DWC) announced proposed amendments to the Medical-Legal Fee Schedule yesterday, May 3.

    The amendments would make significant changes to medical-legal billing practices. These changes include new limits on billing under the Official Medical Fee Schedule (OMFS), and new rules for the application of the ever-troublesome complexity factors for codes ML103 and ML104.

    The DWC will accept public comments until 5 pm on Friday, May 18. 

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DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

Drop us a line with any news you would like us to share or any issue that concerns you.

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