Berkshire Hathaway Homestate Companies (BHHC) is failing to process electronic second review appeals, leaving providers in an unacceptable payment limbo. The insurer incorrectly rejects electronic appeals and offers no alternative for providers to submit these appeals for correct payment.
More absurdly, BHHC representatives report that some of the rejected appeals are “in process,” despite having returned the electronic rejections to providers. In other words, BHHC claims to be processing rejected appeals.
As providers cannot request Independent Bill Review (IBR) until the claims administrator completes the second review and issues a final Explanation of Review (EOR), these rejections leave providers (as usual) holding the bag due to another instance of claims administrator ineptitude.
Second Review Struggles
When a DaisyBill provider reached out to us regarding an incorrect rejection from BHHC, our Compliance Team investigated. Soon enough, a pattern of improperly rejected second review appeals emerged.
We also reached out to BHHC’s clearinghouse which reported that BHHC was responsible for the rejections, and confirmed the invalidity of rejection reasons for multiple appeals.
For their part, a BHHC claims representative indicated that two of the appeals in question were received and in process. This is baffling. BHHC (incorrectly) rejected the second review appeals for missing or invalid claim numbers, rather than processing the appeals on the bills’ merits. In a sane world, the claims administrator does not adjudicate a rejected appeal, even when the claims administrator rejected the appeal incorrectly.
Sane, however, rarely describes the world in which workers’ comp providers live and bill.
Providers Bear the Cost
Incorrect rejections and denials are nothing new in workers’ comp. But the trouble at BHHC provides a particularly galling example of the ways in which the billing and payment system is weighted against providers, and how providers constantly bear the burden of claims administrator incompetence.
When the claims administrator incorrectly denies a second review appeal on its merits — that is, when the appeal is accepted, but the claims administrator declines to adjust the payment — the provider must request IBR. If BHHC paradoxically processes the “rejected” second review appeals and denies payment, IBR is the appropriate recourse.
However, providers cannot pursue IBR until the claims administrator fully adjudicates the bill and returns a final EOR. Refusal (or in this case, possible inability) to properly process a second review appeal requires a different, and often more onerous, recourse: filing a lien. If BHHC fails to process the appeals in question, a lien citing breach of duty is in order.
Either way, the system defaults to the provider’s inconvenience.
BHHC’s clearinghouse is working with DaisyBill to investigate this matter with BHHC. Sadly, BHHC has no dedicated electronic billing specialists, nor any other staff with the required expertise. Meanwhile, providers are waiting on correct reimbursement, burdened with the task of chasing their due compensation through no fault of their own.
DaisyBill’s compliance specialists will continue to work on our providers’ behalf to resolve this latest imposition on providers. Stay tuned to this blog for future updates.
With everything that can go wrong in workers’ comp billing and payment, providers need billing agents who know their stuff. DaisyBill makes billing easier, faster, and less complicated for providers. And when necessary, our Compliance Team gets involved on behalf of our clients. Schedule a free demonstration of our Billing Software below!