Blog: Daisy News

Maximus Federal Services, the private entity which conducts Independent Bill Review (IBR) on behalf of California’s Division of Workers’ Compensation (DWC), has always demonstrated an imperfect understanding of workers’ comp billing rules and regulations. So it’s sadly unsurprising that recently, Maximus imposed inexplicable demands on a California provider for documentation to resolve several billing disputes.

Maximus claimed that the final Explanations of Review (EORs) the provider included in their request for IBR were insufficient, insisting the provider produce complete EORs — despite the fact that EORs are sent by the claims administrator, not the provider.

In other words, Maximus is making impossible demands of the provider as a condition of conducting IBR.

Most claims administrators lack the technology to process electronic bills from providers. Instead, these claims administrators rely on clearinghouses. Since DaisyBill has direct access to all 6 California clearinghouses, we’re uniquely qualified to evaluate and compare the performances of each. With this series, we take a look at the value each clearinghouse adds to (or subtracts from) workers’ comp.

StoneRiver P2P is unique among clearinghouses, in that it insists on charging providers and their e-billing agents for unnecessary and unwanted services. As workers’ comp strives for lower costs, increased efficiency, and better outcomes for all concerned, this kind of wastefulness holds everyone back.

As technology streamlines the system and reduces the need for intermediaries, companies like StoneRiver may find themselves

up an actual creek

.

For California workers’ comp providers, reporting is an important (if sometimes burdensome) requirement. Documentation is everything, hence the requirements for reports like the Doctor’s First Report of Occupational Injury or Illness (Form 5021) and the Treating Physician’s Progress Report (Form PR-2).

That said, it’s important to note that providers only need to submit these reports to the claims administrator or the claims administrator’s designee. No law or regulation requires providers to send extra reports to attorneys or other parties without compensation.

On April 17, 2018, the New York State Workers’ Compensation Board (WCB) announced its intention to improve medical care for injured workers. Board Bulletin Subject No. 046-1058 included proposed changes to the Medical Fee Schedule, a reduction in paperwork, and other enhancements to improve access to quality medical care.

A recently adopted Medicare Medically Unlikely Edit (MUE) assigned a value of “0” to many common workers’ comp billing codes, including those for acupuncture services. Providers were understandably shocked, and wondered whether the incorporation of this MUE into the Official Medical Fee Schedule (OMFS) meant an end to reimbursement for the services in question.

Now, the Division of Workers’ Compensation (DWC) has resolved the matter, revising the most recent OMFS update to exclude all codes with an MUE assigned value of “0” from the workers’ comp MUE file.

When it comes to protecting your office’s revenue, maintaining detailed and accurate records is crucial. Especially when disputes over billing and payment arise, it’s often the party with the most complete, confirmed documentation that prevails.

That’s why a superior, intuitive, easy-to-use Bill History function was a special focus in the design and implementation of our Billing Software.

California’s Division of Workers’ Compensation (DWC) ordered an update to the Pathology and Clinical Laboratory section of the Official Medical Fee Schedule, bringing the OMFS into line with Medicare’s 2018 third quarter changes to reimbursement.

The update adds one billing code, 0037U for targeted gene sequencing. The change is effective for service rendered on or after July 1, 2018.

The World Health Organization (WHO) released an initial version of its 11th International Classification of Diseases and Related Health Problems (ICD-11). Vastly larger than ICD-10 and fully electronic, ICD-11 makes significant changes to the classification of diseases — changes that will ultimately have a major impact on medical billing.

While ICD-11 is officially effective January 1, 2022, the WHO plans to formally present ICD-11 in May 2019 at the World Health Assembly. The WHO released ICD-11 publicly on June 18 of this year to give stakeholders (including California workers’ comp professionals) the chance to start planning for the transition.