Broadspire, A Crawford Company, is another example of a claims administrator that disregards California regulations with impunity.

After accepting a compliant and timely electronically transmitted Second Review appeal sent by a provider, Broadspire never responded to the appeal. When contacted, Broadspire stated that while it accepted the electronic appeal, the appeal was not processed because Broadspire only processes appeals mailed by providers. Which begs the question: what is the point of accepting an electronic appeal that Broadspire will never process? 

Despite California regulations to the contrary, Broadspire cannot process Second Review appeals transmitted electronically by California providers. Yep. It is just that simple.

We’re going to recount a kafkaesque example of the Broadspire version of bill processing. In this nightmare, the provider initially sent Broadspire a timely and compliant electronic Second Review appeal, which Broadspire flat-out failed to process. The provider subsequently acquiesced to Broadspire’s demand and mailed a paper duplicate Second Review appeal to Broadspire. Broadspire denied the mailed appeal. Unbelievably, the reason given for the denied appeal: untimely receipt of the mailed duplicate appeal.

Even though the provider’s initial electronic Second Review was 100% compliant with California law and Broadspire was 100% noncompliant in processing that appeal, Broadspire still contorted California law and refused to properly reimburse the provider.

For a moment, just think about the fundamental unfairness of that...

Providers are given no viable recourse to demand that Broadspire follow California regulations while Broadspire can, with no fear of consequences, inflict payment abuse on providers who treat injured workers.

Provider = 100% Compliant

This provider compliantly followed all three required steps to submit a Second Review to dispute an incorrect reimbursement. Because the provider’s Original bill was transmitted electronically, per California regulations instructions, the provider also transmitted the appeal electronically.

California electronic billing rules require claims administrators to return an electronic acknowledgment receipt which verifies Broadspire received the Second Review appeal transmitted by the provider. Unlike when appeals are mailed, with electronic billing, the provider receives verification that the claims administrator received the bill or appeal. Electronic billing eliminates appeals ‘lost in the mail’ because the claims administrator acknowledges receipt of the appeal.

This verification acknowledgment is referred to as X12 277 Healthcare Claims Status Response. Below is the 277 response the provider received from Broadspire acknowledging Broadspire’s receipt of the provider’s electronically transmitted Second Review appeal.

Broadspire = 100% NON compliant

California regulations require the claims administrator to process and respond to the Second Review appeal within 14 calendar days of receipt. In the case of this Second Review appeal, CCR § 9792.5.5. requires Broadspire to respond no later than 7/20/2020.

When Broadspire failed to respond the provider contacted DaisyBill and DaisyBill contacted Broadspire. DaisyBill was already in the process of trying to determine the reason for Broadspire’s noncompliance. DaisyBill had contacted Broadspire through Availity, the electronic clearinghouse hired by Broadspire, on 6/9, 6/15, 6/18, 6/30, 7/1, 7/9, 7/21, 8/3, and 8/11 about the missing Second Review responses.

On 8/14/2020, Broadspire, through Availity, finally responded to DaisyBill with the message that Broadspire cannot accept Second Reviews electronically. Broadspire defies California law and is imposing two requirements that are directly opposite of what the law states. According to Availity, Broadspire is requiring that:

1. Providers mail their Second Review appeals, even though the law requires that electronic Original bills be appealed electronically.
2. Providers include the Original bill’s explanation of review (EOR), thereby implementing non-existent Second Review rules. California regulations do not require an EOR to dispute an incorrect payment.

On 8/26/2020, as instructed, this provider snail-mailed its Second Review appeal to Broadspire.

On 9/7/2020 Broadspire denied the mailed Second Review appeal as untimely.

Broadspire knows denying the Second Review appeal will just prolong the grinding process that pulverizes providers until they can no longer justify the expenditure of resources to demand reimbursement justice.

Like so many other claims administrators, Broadspire can systematically ignore California laws that impose responsibilities on claims administrators, while simultaneously using the complexity of California laws to repeatedly deny proper reimbursement. Yep, it’s that simple.

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