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CA Claims Admins Fail to Comply With IBR Rules

September 7, 2018 by Catherine Montgomery

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 includes not only the correct reimbursement for the original bill, but also 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, some claims administrators are either ignorant of these requirements, or choose to ignore them in acts of blatant non-compliance.

Non-compliant Claims Admins

Following complaints from some of our providers, we discovered several cases of claims administrators failing to remit payment within the mandated timeframe. According to California Labor Code Section 4603.2, claims administrators have 45 days to pay, from the date on the letter Maximus sends to the claims administrator announcing the IBR decision.

The 45-day deadline, as well as the requirement to restore the $195 filing fee to the provider, is clearly laid out in that letter. Below is one such letter, which Maximus sent to third-party administrator Sedgwick Claims Management (emphasis in red our own):

When Sedgwick failed to timely remit payment, DaisyBill reached out to Sedgwick for answers. After several attempts to resolve the situation, Sedgwick assured us that payment was sent, albeit past due.

It should not take multiple phone calls from a provider’s e-billing agent to induce a claims administrator to meet their obligations. It shouldn’t take even one phone call, or anything at all apart from Maximus’ letter. But Sedgwick is not the only claims administrator behaving badly.

  • Self-insured employer PG&E also missed the deadline to remit payment following IBR. Again, it took multiple calls before PG&E confirmed that the (late) payment was on its way, a waste of provider time that adds insult to the injury of forcing the provider to request second review and IBR in the first place.

  • TPA Tristar Risk Management timely remitted correct payment for services rendered, but did not include the $195 IBR filing fee, which the claims administrator must restore to the provider when Maximus rules in the provider’s favor. In this case, the filing fee actually exceeds the amount owed for services rendered!

  • Protective Insurance has yet to remit payment for an IBR decision from July 9 of this year, despite repeated outreach from DaisyBill, including one phone call in which our representative had to explain the IBR process to Protective’s claims adjuster.

It should go without saying, but this behavior is unacceptable.

If necessary, the provider has one option to compel payment from the claims administrator in cases like these: filing a petition to enforce IBR under California Code of Regulations (CCR) Section 10451.4. The petition may include a request for penalties and interest at the rates set forth in Labor Code § 4603.2(b) and/or § 4622(a).

It is absurd to think that following IBR, providers should have to expend more time and resources simply to obtain what’s owed. We would hope that when proven wrong in a dispute, claims administrators would act in good faith and follow the DWC’s directives.

Apparently, for some claims administrators, our hopes are misplaced.


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