A disturbing pattern is emerging from the results of Independent Bill Review (IBR) decisions in the state of California. As usual, the problem encumbers workers’ comp providers with extra legwork in order to receive proper reimbursement from claims administrators.
A flaw in the state’s enforcement mechanism — or complete lack thereof — leaves providers without proper reimbursement long after prevailing in IBR cases. Months after the final decision, claims administrators have yet to remit the disputed amounts, and/or to restore the $195 IBR filing fees to providers.
When the claims administrator declines to remit correct payment following second review, providers must escalate to IBR. California’s Division of Workers’ Compensation (DWC) delegates IBR to Maximus, a private company that acts as arbiter on behalf of the state.
When Maximus overturns the claims administrator’s final Explanation of Review (EOR) and grants the provider further payment, California Labor Code 4603.2.(2)(A) requires the claims administrator to remit both the disputed amount and the $195 IBR filing fee within 45 days of the date on Maximus’ Final Determination Letter.
As we work to ensure correct reimbursement for our providers, we come across far too many cases in which claims administrators refuse to comply with IBR regulations, and timely remit full payment. In the past, we chronicled the ridiculous lengths providers must go to, thanks to the scofflaw behavior of claims administrators including:
Since then, other claims administrators have failed to meet their legal obligation to providers.
Sedgwick Claims Management Services
In February of this year, a provider requested IBR to dispute incorrect payment from Sedgwick. Maximus overturned Sedgwick’s EOR, with a final IBR decision date of May 3. Sedgwick had until June 17 to remit the disputed amount and the IBR filing fee.
On May 13, Sedgwick paid only the disputed amount. Our Compliance Team spoke several times with a Segwick representative, who ultimately claimed that Sedwick intends to pay the full amount.
As of this writing, Sedgwick has yet to remit the $195 filing fee amount owed to the provider.
In March of this year, a provider submitted a request for IBR to dispute payment from Gallagher Bassett. Maximus overturned GB’s final EOR, with a final decision date of May 16, and a due date for full payment of June 30.
By July 1, GB had yet to remit payment. After multiple unanswered voicemails to GB’s adjuster, our Compliance Team finally spoke with the adjuster’s supervisor. GB issued full payment on July 24.
Complications due to a change of claims administrators, combined with a characteristic fumble from Maximus, continue to delay payment in this frustrating IBR case.
In March of this year, a provider submitted a request for IBR disputing payment from Athens. Maximus overturned Athens’ final EOR, with a decision date of May 16 and a payment due date of June 30. On July 2, our Compliance Team reached out to Athens, as the provider received no payment. An Athens representative explained that because claims for the employer in question were transferred to Travelers, Travelers is now liable for the additional payment.
To make matters even more ridiculous, a mistake in Maximus’ Final Determination Letter subtracted the disputed amount from the $195 IBR filing fee, instead of adding the two amounts to arrive at the correct total payment. A Travelers representative claimed that Travelers will only pay the incorrect amount miscalculated by Maximus, rather than the correct amount.
Our Compliance Team spoke with the Travelers’ adjuster and explained Maximus’ calculation error. Travelers issued full payment on July 26.
Helmsman Management Services
In March of this year, a provider requested IBR to dispute payment from Helmsman. Maximus overturned Helmsman’s final EOR, with a final decision date of May 29 and a due date for full payment of July 13.
On July 8, Helmsman paid only the $195 IBR filing fee, not the disputed amount. When our Compliance Team reached out to Helmsman’s adjuster, the adjuster was unable to resolve the matter, as she had never heard of IBR generally (!). The adjuster agreed to follow up with Helmsman’s billing department.
Helmsman issued payment for the disputed amount on July 31.
Rigged System Without Payor Consequences
An authority without enforcement of its decisions is no authority at all. If claims administrators are this comfortable disregarding Maximus’ rulings, providers have little reason to believe that treating injured workers will result in fair compensation.
As repeatedly shown, such a lack of consequences for noncompliance is an invitation for malfeasance of all kinds, to the detriment of the entire workers’ comp system.