CA Claims Admin Delays Payment, Skirts IBR Rules

CA Claims Admin Delays Payment, Skirts IBR Rules

When the Independent Bill Review (IBR) process overturns a claims administrator’s incorrect denial or adjustment, the claims administrator is legally bound to timely pay what they owe. That payment must include both the correct reimbursement for the original bill and the $195 IBR fee the provider paid to initiate the appeal.

Claims administrators have 45 days to comply with the IBR decision and pay in full.

Unfortunately, Tristar chooses to ignore these payment requirements in an act of blatant non-compliance. Sadly, there is no recourse for the provider except to continue to beg for Tristar’s compliance.

Exhaustive Odyssey For Payment

On 6/12/2018 Maximus Federal Services, responsible for conducting Independent Bill Review (IBR) for California’s Division of Workers’ Compensation (DWC), issued an OVERTURN IBR decision against Tristar, the claims administrator handling workers' comp claims for the City of Los Angeles. Tristar did finally issue payment, but only after a continuous and exhaustive effort.

Not playing by the IBR rules is certainly nothing new for claims administrators. And fighting to recover the filing fee is something providers must expect. But, below, you can see from the timeline for this particular recovery that it dates back over four months.

From IBR Decision to Payment:

  • 6/12/18: Maximus IBR overturns Tristar payment denial.
  • 7/27/18: Due date for reimbursement of disputed amount and IBR filing fee.
  • 7/30/18: DaisyBill legal counsel speaks to Tristar’s bill review firm, Medata, whose representative confirmed knowledge of the IBR decision and Tristar’s obligation to pay.
  • 8/15/18: Voicemail #1 left with Tristar’s adjuster, requesting payment.
  • 8/22/18: Voicemail #2 left with adjuster requesting payment.
  • 8/29/18: Conversation #1 with adjuster by phone and IBR decision emailed to adjuster, who made assurances that payment would be remitted.
  • 9/12/18: Email #1 sent to adjuster requesting payment.
  • 9/18/18: Email #2 sent to adjuster requesting payment.
  • 9/26/18: Conversation #2 with adjuster by phone, who indicated no response from Medata following a request for information.
  • 10/15/18: Email #3 sent to adjuster requesting payment update.
  • 10/16/18: Voicemail #3 left for adjuster's supervisor requesting payment update.
  • 10/17/18: Conversation #3 with adjuster's supervisor who instructs us to contact Medata, since Tristar's internal notes on the file (dated 6/26) indicate Medata disputed the IBR.
  • 10/7/18: Voicemail #4 left with Medata.
  • 10/18/18: Voicemail #5 left with Medata.
  • 10/22/18: $195 Filing Fee finally received, dated 10/17/2018.

As indicated above, DaisyBill’s Compliance Team left 5 voicemails, sent 3 emails and had 3 conversations trying to recover the $195.00 IBR fee from Tristar.

Claims administrators lack accountability when providers seek just compensation in a timely fashion, an accepted hurdle in our landscape which is neglect for the law.

Contact DaisyBill when claims admins are giving you the runaround. Learn more with our free billing software demo. Schedule today.


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