Proposed legislation in California would allow the state’s Independent Bill Review (IBR) organization (Maximus) to invoice the payer (aka claims administrator) for the review costs of an IBR, when the doctor prevails in the dispute.

If Assembly Bill 399 passes, doctors would pay a $50 “eligibility fee” to determine if the dispute qualifies for IBR. For eligible disputes, Maximus would collect the remaining review fees from whichever party (the doctor or the payer) does not prevail in the dispute.

This extremely important legislation would address a glaring flaw in the IBR process.

Currently, payers deny correct reimbursement, essentially betting the doctor won’t risk the $180 IBR filing fee to pursue proper payment. Repeatedly, we’ve seen payers deny payment → deny again on Second Review → then suddenly reverse course and pay only when the doctor pays $180 to request IBR (a little game we call “IBR Chicken”).

By playing “IBR Chicken,” the payer can reimburse the doctor $0 for treating an injured worker unless the doctor is willing to risk $180, and the Division of Workers’ Compensation (DWC) deems the dispute eligible for IBR, and Maximus rules in the doctor’s favor — and even then, the payer laughs (and laughs and laughs) while the doctor waits (and waits, and waits) for the payer to remit the $180 back to the doctor.

By making it less costly to initiate IBR, AB 399 may rein in “IBR Chicken,” and stop payers from shirking their obligation to reimburse doctors the $180 IBR filing fee, when the doctor prevails. Read on for the precise details of this this important change to IBR fees.

$50 to Initiate IBR

To dispute incorrect payment amounts, currently doctors pay $180 to request IBR. If the DWC deems the dispute ineligible for IBR, Maximus refunds $132.50 to the doctor, and keeps the remaining $47.50.

If the DWC deems the payment dispute eligible for IBR, and Maximus overturns the payer’s payment amount, the payer must reimburse the $180 IBR fee to the doctor — a requirement payers are notorious for ignoring.

Under AB 399, if passed, IBR would work as follows:

1. The doctor remits the $50 eligibility fee “electronically, using a method that allows the independent bill review organization to collect additional fees, if warranted.”
2. If the DWC deems the payment dispute IBR-ineligible, the doctor forfeits the $50, and must file a lien to dispute the payment amount or denial.
3. If the DWC deems the dispute IBR-eligible and Maximus upholds the payer’s payment amount:

1. Maximus assesses the doctor the “additional review fees” using the electronic payment method with which the doctor remitted the initial $50 eligibility fee.
2. If the additional review fee payment fails to process, the doctor must remit the additional review fees within 10 days, or penalties and interest apply.

4. If the DWC deems the dispute eligible and Maximus overturns the payer’s payment amount:

1. Maximus refunds the $50 to the doctor within 5 business days of the IBR decision.
2. Maximus sends the payer an invoice for 100% of the eligibility and review fees.
3. The payer must pay the Maximus invoice within 30 days; after 40 days, penalties and interest apply.

Yes, payers are allowed 40 days to pay Maximus’ invoice while doctors are only allowed 10 days. For failure to timely pay Maximus the review fee, the party that did not prevail in the dispute (either the doctor or the payer) incurs penalties and interest as follows:

“...there shall be added an additional amount equal to 10 percent, plus interest at the legal rate, which shall be paid at the same time but in addition to the total aggregate fee.”

Inequitable time frames for paying the review fees aside, the new process would be a HUGE win for doctors. Chasing payers to recover the $180 IBR filing fee is a daily chore for daisyBill and our clients; in fact, all the payers listed below currently refuse to provide daisyBill doctors proof of restitution of the IBR filing fee:

Altogether, AB 399 is a BIG step in the right direction. However, only time will tell if this well-intentioned legislation will pass, and actually put a stop to the game of “IBR Chicken,'' which payers employ as a strategy to deny payment to the doctors who treat injured workers.

daisyBill has the technology and expertise to make workers’ comp work better. Reach out to see how we can help your practice obtain fast, correct reimbursement for treating injured workers.

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