Blog: Daisy News

California regulations mandate that when Independent Bill Review (IBR) overturns a claims administrator’s incorrect bill denial or adjustment and finds in favor of the provider, the claims administrator must reimburse the provider for the $195 IBR filing fee, in addition to the disputed amount owed.

Unfortunately certain claims administrators, including TriStar Risk Management, Protective Insurance, and Acclamation Insurance ignore this important rule, forcing providers to go to preposterous lengths to recover the full amount due.

In California, physicians use code ML106 to bill for supplemental medical-legal examinations. However, what constitutes a supplemental medical-legal exam for billing purposes can be hard to pin down. Physicians and their billing staff, understandably confused by the regulations, can sometimes mistakenly use ML106 to bill for services that do not qualify.

In particular, there are four scenarios in which physicians regularly, but mistakenly, apply ML106 — which leads to time-consuming bill denials.

Maximus Federal Services, the entity responsible for conducting Independent Bill Review (IBR) on behalf of California’s Division of Workers’ Compensation (DWC), has once again demonstrated a level of incompetence to which only a brave few can aspire.

Maximus not only fumbled its interpretation of procedure code 99358 — again — but also committed a mathematical error amateurish enough to shake whatever confidence remains in the company’s capacity as a competent arbiter of billing disputes. For the provider in question, Maximus created a nightmare scenario that would be laughable if it wasn’t so infuriatingly unjust.

Since an update to California’s Official Medical Fee Schedule (OMFS) made non-face-to-face services reimbursable again in 2017, there’s been confusion aplenty about how to properly bill and pay for billing codes 99358 and 99359. Even now, providers and payors continue to struggle with the rules regarding these tricky time-based codes.

Recently, a DaisyBill client alerted us to one bill review service’s mistake regarding the relationship between the time the provider spends on non-face-to-face services and the number of units the provider may bill for code 99359. We’re happy to clear up the confusion.

To appeal incorrect reimbursements or bill denials, California providers must submit timely and compliant requests for second review. To date, DaisyBill clients have recovered over $30 million in additional revenue by submitting these second review appeals.

But claims administrators aren’t the only ones who make mistakes.

Providers should also submit a second review appeal if, upon receiving an Explanation of Review (EOR), the provider determines that the original bill was submitted incorrectly. But crucially, providers may not make any adjustments to the original bill. The bill a provider submits with a second review request must be exactly the same as the original, with no changes other than those designating the submission as a second review appeal.

California’s Division of Workers’ Compensation (DWC) issued an update to Medical Treatment Utilization Schedule (MTUS) drug formulary, effective October 1, 2018. The formulary identifies which drugs providers must obtain prospective authorization from the claims administrator to prescribe or dispense.

The update order adds 28 drugs to the list — almost all of which require authorization — bringing the total number of listed drugs from 283 to 311.

Providers, take note: California’s Division of Workers’ Compensation (DWC) announced that the Medi-Cal pharmaceutical fee data file, updated weekly, was replaced for the week of September 5, 2018.

The DWC encourages any providers who downloaded this file to update it with the replacement file, and to recalculate any reimbursements based thereon.

In April, the California Division of Workers’ Compensation (DWC) held a hearing regarding the inclusion of the Medicare Geographic Practice Cost Indices (GPCI) in the Physician and Non-Physician Practitioner portion of the Official Medical Fee Schedule (OMFS).

Now, it appears the DWC will almost certainly move forward with the plan to adjust reimbursement based on provider location.

The DWC issued a notice of proposed modifications to the Physician fee schedule, effective on January 1, 2019, which include GPCI calculations. A 15-day public comment period ends on September 14.