Blog: Daisy News

When the Independent Bill Review (IBR) process overturns a claims administrator’s incorrect denial or adjustment, the claims administrator is legally bound to timely pay what they owe. That payment must include both the correct reimbursement for the original bill and the $195 IBR fee the provider paid to initiate the appeal.

Claims administrators have 45 days to comply with the IBR decision and pay in full.

Unfortunately, Tristar chooses to ignore these payment requirements in an act of blatant non-compliance. Sadly, there is no recourse for the provider except to continue to beg for Tristar’s compliance.

On Tuesday, October 9, Optum Property and Casualty Clearinghouse suffered a major systems issue, preventing Optum from receiving, processing, or responding to electronic bills from providers. The shutdown persisted for a week, until Optum was able to restore systems on Tuesday, October 16.

After resolving the glitch, Optum pledged to contact all clients and partners individually to ensure that all data is accounted for, and ultimately processed. DaisyBill clients can rest easy, as our automated systems keep track of all data, response times, and tasks required to complete the billing and payment process.

In a much-anticipated ruling, California’s Supreme Court ruled that a secondary injury derived from an incorrect Utilization Review (UR) decision is compensable under workers’ comp.

The Supreme Court denied the injured worker’s right to sue the Utilization Review Organization (URO) and UR physician in civil court, affirming workers’ comp as the “sole and exclusive remedy” for all injuries that arise out of or occur in the course of employment — including additional injuries that result from improper UR decisions regarding accepted injuries.

A recent refusal by Travelers Insurance to respond to a provider’s second review appeal, and subsequent denial of the provider’s request for Independent Bill Review (IBR), perfectly illustrate significant flaws in California’s process for disputing incorrectly denied or adjusted workers’ comp bills.

Travelers ignored the provider’s second review appeal, and subsequently the provider’s IBR request was denied on the grounds the provider failed to submit Travelers’ (non-existent) response to that second review appeal. In effect, Travelers brought the appeal process to a halt simply by refusing to participate.

Fortunately, there is a recourse. Unfortunately, it means even further hassle for the provider.

Recently, MARS (Medical Audit and Review) made a very strange — and very dubious — offer to a California provider on behalf of the claims administrator, Farmers Insurance.

After Farmers denied the provider’s bill, the provider appropriately appealed with a request for second review. But before Farmers could return a decision and final Explanation of Review (EOR), MARS reached out to the provider with a proposed settlement, offering the provider roughly half the required reimbursement amount.

This is a classic example of a disturbing syndrome in workers’ comp, one of which providers should be very wary: excessive, redundant, and pointless bill “auditing.”

California’s Division of Workers’ Compensation (DWC) has pulled the trigger: Geographic Practice Cost Indices (GPCI) will take effect on January 1, 2019. GPCI will divide the state of California into 32 distinct pricing regions, adjusting reimbursements for Physician and Non-Physician Practitioner services based on specific location.

The plan is an effort to more fairly compensate workers’ comp providers with respect to the widely varying costs associated with running a practice in different areas.

California’s Division of Workers’ Compensation (DWC) ordered updates to the Hospital Outpatient and Ambulatory Surgical Center (ASC) portion of the Official Medical Fee Schedule (OMFS), effective October 1, 2018. The updates bring the OMFS into line with changes to the Medicare payment system.

The update lowers reimbursements for 193 billing codes.

California’s Division of Workers’ Compensation (DWC) proposed significant changes to the Pharmaceutical Fee Schedule. The proposals would bring pharmaceutical reimbursement calculations for workers’ comp into line with revisions to Medi-Cal’s payment system, on which the Pharmacy Fee Schedule is based.

If approved, the proposed changes will be effective January 1, 2019. The DWC will accept public comments via their online forum until Monday, October 8.