Blog: Daisy News

News, data, & insights about workers' comp billing

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  • June 1, 2018

    Multiple Payors Reimbursing WC002 at 2017 Rates

    We’re halfway through 2018, and claims administrators are still reimbursing your office at 2017 rates for 2018 dates of service.

    We’ve noticed this problem all year for various billing codes. We’ve called on claims administrators to update their systems to reflect California’s current Official Medical Fee Schedule (OMFS). Now, inexplicably, we see a particular code (WC002) paid at 2017 rates for 2018 dates of service — even as other codes on the same bill are paid correctly.

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  • May 31, 2018

    Institutional Billing: How to Find Your Conversion Factor

    For institutional billing, identifying the correct conversion factor is key to saving time and billing accurately.

    The Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule is a testament to just how convoluted California workers’ comp billing can be — even the schedule’s title is long and messy. Among its many complications are the county and hospital-specific wage-adjusted conversion factors, which providers must include when calculating reimbursement amounts.

    These conversion factors can be tough to identify, and are always subject to change.

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  • May 30, 2018

    E/M Services Denied for Insufficient Documentation

    Increasingly, claims administrators are no longer downcoding evaluation and management (E/M) services. Instead, many claims administrators are denying charges for E/M services due to insufficient documentation.

    Even when E/M services are indicated on the  Primary Treating Physician’s Progress Report (PR-2) form, providers who do not use the allotted space on the PR-2 to fully substantiate the level of E/M service may find the charge denied. Some claims administrators are paying only for the PR-2 report itself — meaning providers receive just $12.46 for each visit.

    What’s more, Maximus Federal Services, the private entity that conducts Independent Bill Review (IBR) on behalf of the State of California, is upholding these E/M charge denials. Without the extensive documentation claims administrators demand, providers are likely to lose such appeals.

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  • May 25, 2018

    Data Reveals Importance of Second Review Appeal for Providers

     

    The claims administrator’s Bill Review does not always recommend the correct reimbursement on the first try. Our second review appeal data reveals a staggering amount of revenue that — without provider action — would be lost due to bill review errors.

    As of this writing, DaisyBill clients have submitted 393,947 requests for second review appeals. From those appeals, our clients collected $28,668,998.82 in additional reimbursement.

    Sadly, it’s a provider’s responsibility to resolve such errors. If a provider wants correct reimbursement for treating injured workers, the provider must check payment amounts against Official Medical Fee Schedule (OMFS) reimbursement rates. When the numbers don’t add up, the provider must take the necessary steps to secure compensation.

     

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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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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.