Blog: Daisy News

Pacific Claims Management responded to our August blog regarding misinformation about requests for Second Bill Review. DaisyBill spoke with a Pacific representative, with whom we also discussed concerns regarding changes to Pacific’s processing of electronic bills. Happily, not only did Pacific rectify both issues, they displayed a level of transparency and responsiveness that does the claims administrator credit.

We believe that Pacific’s willingness to engage in discussions like these ultimately benefits Pacific, the providers that send bills, and the workers’ comp system as a whole.

A client of DaisyBill recently brought to our attention another poor Independent Bill Review (IBR) by Maximus Federal Services, the entity the California Division of Workers’ Compensation (DWC) contracts to review and decide on IBR requests submitted by providers. The IBR decision concerns procedure code 0232T for platelet-rich plasma injection. In the past, Maximus decided in favor of the doctor in the majority of IBRs submitted for 0232T. However, recently Maximus inexplicably changed the criteria for reviewing 0232T, and started to issue denials of payment for this procedure code.

That’s because Maximus is making these important payment decisions without referencing California Labor Code, California Code of Regulations, or administrative rules.

Multiple providers allege that a major clearinghouse fed them inaccurate information about electronic billing in California. According to these providers, the clearinghouse in question insists that many claims administrators do not accept e-billing for worker’s comp, necessitating paper bills. In truth, every major claims administrator in California does, in fact, accept e-bills.

This casts serious suspicion on the clearinghouse’s motives.

A well-crafted intake form, targeted to the California Division of Workers’ Compensation (DWC)’s billing guidelines, is the provider’s first line of defense against incorrect reimbursement. According to the DWC, a bill must be one thing above all to be considered compliant: complete. For providers, ensuring that completeness starts at intake.

Fortunately, DaisyBill has that covered.

You may recall last month’s dismissal of over 292,000 unresolved liens by California’s Division of Workers’ Compensation (DWC). The DWC closed the lien cases for failure to comply with new declaration requirements mandated by SB 1160. On August 14, 2017, the DWC dismissed the liens on procedural grounds “by operation of law." The dismissed liens are now publicly available through a searchable database posted on the DWC website.

Maximus Federal Services, the arbiter of Independent Bill Review (IBR) for the California Division of Workers’ Compensation (DWC), has denied payment to a provider due to a an error on Maximus’ own part. The mistake, based on an outdated status code designation for CPT codes 99358 and 99359, is one DaisyBill anticipated. With Maximus behind the curve on changes to the Official Medical Fee Schedule (OMFS) effective this year, other providers may be in danger of the similar mistreatment.

Discount Dangers is a DaisyBill series on the various ways discount contracts incorrectly reduce providers’ reimbursements. With this series, we shine a light on the worst discount practices, and help providers fight back.

Providers have rights.

We can’t state this strongly enough. In so many ways, the California workers’ compensation system is rigged against providers. That’s why it’s vital for providers to know exactly how the law protects them from unfair treatment and improper reimbursement. This is particularly crucial when it comes to discount contracts, which are often abused in ways that are more than just unfair; they’re also non-compliant.

Recently a claims administrator gave a DaisyBill client some horrible advice about appealing an incorrect payment.

A representative at Pacific Claims Management, a third party administrator, reportedly instructed the DaisyBill client not to bother using an SBR-1 form to appeal an incorrect payment. Fortunately, our client reached out to us to ask why Pacific Claims Management gave these inaccurate instructions.