Workers’ comp providers, be warned: payors are incorrectly denying bills for automatically authorized services due to untimely submission.
Untimely submission is not grounds for denial of payment under California’s new automatic authorization system. While the deadlines for bill submission are much shorter for automatically authorized services, no provision whatsoever bars payment when providers miss said deadlines.
Senate Bill 1160 replaced Labor Code Section 4610 with a revised version, effective January 1, 2018. The current § 4610 introduced the new automatic authorization system and its tighter submission deadlines for bills for automatically authorized services. As we’ve discussed before, providers should submit bills for automatically authorized non-emergency treatment within 30 days of treatment (and within 180 days for emergency services).
However, nothing in the new § 4610 — or in any regulation — bars payment when the provider submits the bill after the 30 or 180-day deadlines. Under existing rules for automatic authorization, deadlines exist, but mandated consequences do not exist for violating timely submission of these bills.
Explanations of Review (EORs) from one payer (generally an impressively prompt payor) listed the following reason for denial of payment for automatically authorized services:
Labor Code 4610 non-emergency treatment bills performed within the first 30 days of injury shall be submitted within 30 days of the date the service was provided.
The payer may see this is fair play, given the timeframes. The insurer may count on providers being uninformed, or themselves be uninformed. Regardless, while SB 1175 releases payors from any obligation to pay a standard, untimely submitted bill, this rule does not apply when services were automatically authorized.
DaisyBill always advocates for provider compliance. However, denial of payment is not a permissible response to bills for automatically authorized services, even with an assertion that providers violated automatic authorization timeframes.
For automatic authorization, if a bill is untimely submitted, or if the required Request for Authorization (RFA) is untimely submitted, or even if the service falls outside the bounds of the Medical Treatment Utilization Schedule (MTUS), payors cannot deny payment under current regulations, as we explained in an earlier blog.
Payors can punish a pattern of treatment inconsistent with the MTUS by removing the provider from the MPN or HRO, or by removing the provider’s permission to provide automatically authorized treatments. However, payors currently have no way to address untimely bill submission, nor can providers deter a provider’s behavior by withholding payment. Payment is due, regardless of when the bill arrives.
Second Review for Automatically Authorized Services
We encourage providers to play by the rules. We also encourage providers to know their rights as California workers’ comp stakeholders navigate implementation of automatic authorization.
Be sure that treatments meet the 6 qualifying conditions for automatic authorization. Submit the Doctor’s First Report of Occupational Injury or Illness (DLSR 5021) and compliant RFA within 5 days of treatment. And of course, submit all bills within mandated timeframes.
But to the extent that your office fails to meet the required deadlines, understand that this does not preclude payment.
Until new regulations specify otherwise, provider timeliness is irrelevant. If your office is denied payment for untimely bill submission where the service was automatically authorized, we recommend requesting second review. We offer a sample letter with sufficient language to support your bill for inclusion with your SBR-1, which you may download here.
If the rules change, we’ll update our readers. For now, providers can rest assured that untimely submission, while not advisable, is not grounds for denial of payment.
For more on automatic authorization, see our Complete 2018 Automatic Authorization Guide for California Workers’ Comp
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