Blog: Daisy News

News, data, & insights about workers' comp billing

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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.

    Read more →

  • February 23, 2018

    VPay Error Impacts Thousands of Sedgwick EORs

    VPay, a payment processing company which issues explanation of reviews (EORs) and virtual credit card payments from claims administrators to providers, suffered a technical glitch in early November 2017.  VPay did not timely send thousands of EORs denying payment from Sedgwick Claims Management Services.

    To rectify the glitch, VPay recently flooded providers with EORs denying payment on Sedgwick’s behalf. Some of the EORs recently received by providers are dated as far back as November.

    Crucially, these EORs are backdated to the date processed, rather than reflecting the date on which VPay actually sent the EORs out. This falsely alters the timeline, potentially narrowing or closing the timeframe in which providers may request second review. Providers should review these EORs, submit timely requests for second review where necessary, and submit audit complaints regarding Sedgwick’s flagrant violation of relevant Labor Codes.

    Read more →

  • February 15, 2018

    How to Bill for Physician-Dispensed Pharmaceuticals

    Payments for physician-dispensed drugs are some of the most misunderstood — and incorrectly denied — in workers’ compensation billing. Too often, the employer or insurer’s claims administrator denies payment based on inapplicable Physician Fee Schedule status code rules. Beyond that, the Division of Workers’ Compensation (DWC) and state legislature seem keen to discourage physician dispensing.

    Regardless, physicians have permission to dispense pharmaceuticals, and to bill according to the Pharmacy Fee Schedule.

    Read more →

  • February 13, 2018

    Providers: Don’t Accept 2017 OMFS Reimbursement Rates for 2018 Dates of Service

    Lately, we’ve noticed a problem. Some claims administrators are reimbursing providers incorrectly. Instead of paying the higher 2018 Official Medical Fee Schedule (OMFS), claims administrators are paying last year’s lower 2017 reimbursement rates for services rendered this year. This is not acceptable. In these cases, it’s up to the provider to protect their revenue.

    Fortunately, there are tools for providers to calculate — and obtain — proper reimbursement.

    Read more →

  • February 7, 2018

    “Automatic” Authorization, but Denied Bill? How to Appeal the Denial

    The new “automatic” authorization process for workers’ comp is in effect, as of January 1. We’ve discussed this new system extensively on our blog and in our recent webinar, covering everything from eligibility to timeliness to new utilization review requirements. But what happens if the employer or insurer’s claims administrator denies payment for automatically authorized services rendered? Does the usual second review appeal process apply?

    In short, authorized is authorized, automatically or otherwise — but in this case, there is a twist.

    For our complete downloadable guide to automatic authorization in 2018, click here.

    Read more →

  • October 19, 2017

    How It Works: Independent Bill Review (IBR)

    Think about what workers' comp providers go through to obtain correct payment for treating injured workers. Compliant authorization and billing are taxing enough. Appealing incorrect reimbursements or denials with a request for Second Review means even more work. Then, when the Second Review appeal fails to produce proper compensation, the only recourse is to navigate yet another onerous process: Independent Bill Review (IBR).

    Fortunately, the IBR process — though extremely burdensome — is navigable, and usually the provider prevails.

    Read more →

  • October 18, 2017

    The Parity Problem: How Work Comp Favors Insurers Over Providers

    In disputes over payment in the California workers’ compensation system, insurers have an unfair advantage over providers.

    At every stage of the billing process, the burden of seeking proper reimbursement falls on the provider. The penalty for provider non-compliance is immediate and automatic: they don’t get paid. Yet, the insurer suffers no consequences for payment non-compliance.

    This lack of parity reveals exactly what value is placed on the role of doctors and other health care workers in the work comp system: very little, indeed.

    Read more →

  • October 6, 2017

    The Provider’s Burden: Appealing Improper Reimbursements

    Worker’s comp billing is hard enough.

    Four years ago, California passed strict requirements that providers must follow to appeal incorrect reimbursements from insurers. These requirements are burdensome to the point of being prohibitive — and insurers know it. Since most providers lack the resources to appeal incorrect payments, insurers and their claims administrators can underpay without fear of consequence.

    With the burden of proof on their shoulders, providers remain vulnerable to the systemic abuse enabled by the Second Review process.

    Read more →

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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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