We do our best to give folks the benefit of the doubt here at daisyBill. However, we can only presume that Athens Administrators deemed the authorized treatment administered to a California firefighter to be worth less than the cost of a postage stamp.

Athens, a third-party claims administrator (TPA), sent a check for $0.51 to the doctor responsible for the care of an injured East Contra Costa Fire Protection District (ECC Fire) firefighter.

Get out your reading glasses; this payment was so small, we had to squint to see it.

Athens authorized the medically necessary treatment for the firefighter, then Athens denied almost the entire reimbursement due to the doctor per the California Official Medical Fee Schedule (OMFS). Almost.

Athens Administrators issued a $0.51 check for…well, we’re not sure exactly what.

As seen above, Athens Administrators’ EOR listed Reduction Reason Code G10 for all charges, with the following description:

We cannot review this service without necessary documentation. Please resubmit with indicated documentation as soon as possible.

Of course, this reduction reasoning is patently FALSE; the doctor sent all of the required documentation with the original bill.

To fully demonstrate the utter randomness with which Athens strips doctors of payment:

1. Athens paid $0.00 for all but one of the authorized treatments.
2. Athens remitted $0.60 (read: cents) for treatment that the OMFS reimburses at $176.93.
3. Athens added insult to (literal) injury with a $0.09 (read: cents) Preferred Provider Organization (PPO) reduction.
4. Athens’ EOR failed to identify the name of the PPO network that made off with the doctor’s $0.09. (Athens frequently takes ‘PPO’ reductions without identifying the responsible network).

The doctor submitted a timely and compliant Second Review appeal to dispute this absurd reimbursement. Thus far, Athens has chosen to ignore the appeal for appropriate reimbursement by failing to timely respond with a final EOR.

As of this writing, Athens Administrators is 33 days late (and counting) to respond to the Second Review appeal.

Doesn’t Authorization Guarantee Payment?

Last we checked, it’s supposed to. The Division of Workers’ Compensation (DWC) webpage ‘Answers to frequently asked questions about utilization review (UR) for claims administrators’ clearly states:

Authorization means "assurance that appropriate reimbursement" for the treatment specified will be paid.

In a Utilization Review (UR) decision letter dated October 21, 2021, Athens Administrators’ senior claims examiner explicitly authorized the evaluation and treatment that the treating physician administered to the firefighter.

Will IBR Chicken Be Next?

IBR Chicken — a wearisome game that providers are clucking sick of.

Though we jest, there’s nothing amusing about the plague of payment abuse ripping through California’s workers’ comp system. Surely, $0.51 (read: cents) does not count as “appropriate reimbursement” for treating an injured firefighter.

Noncompliant claims administrators impose hurdle after hurdle to proper reimbursement. Payers like Athens game California workers comp by simply betting that busy physicians won’t pursue Second Review appeals or Independent Bill Review (IBR).

Unfortunately for Athens Administrators, this physician won’t chicken out.

Tired of claims admins wrongfully denying payment? We can help! Get paid, in full and on time with daisyBill. Contact us to learn more.

CONTACT DAISYBILL