Providers — interpreters in particular — be advised: a California appeals court ruled that claims administrator Meadowbrook Insurance is not required to pay a disputed fee for interpreter services because the interpreter failed to submit a second review appeal before filing a lien.

Second review appeals are the first line of offense after an inappropriate bill denial or reimbursement. For all workers’ comp providers, these appeals aren’t just best practices for revenue management. As this court case demonstrates, the second review appeal is a mandatory step in the billing dispute process that providers skip only at their peril.

For interpreters, this court case is significant; it resolves the question of whether a fee schedule for interpreter services exists, for the purpose of second review appeal and Independent Bill Review (IBR).

The Case

Meadowbrook accepted liability for the claims of two injured workers who required Spanish language interpreter services. DFS Interpreting provided those services and billed Meadowbrook accordingly. When Meadowbrook denied payment, DFS filed a lien in an attempt to collect reimbursement.

DFS’s case was apparently sound on its merits; a workers’ compensation judge ruled that Meadowbrook had to pay. The Workers Compensation Appeals Board (WCAB) agreed, denying Meadowbrook’s petition for reconsideration.

But Meadowbrook had only just begun its fight to deny payment for authorized interpreting services.

Meadowbrook Ins v WCAB

In Meadowbrook Ins. v WCAB  the claims administrator took its case to the Court of Appeal for the 3rd District of California, arguing that because DFS failed to request the second review appeal for payment, the interpreter service could not file liens. Meadowbrook’s argument rested on California Labor Code Section 4603.2, which states (emphasis ours):

...If the only dispute is the amount of payment and the provider does not request a second review within 90 days, the bill shall be deemed satisfied and neither the employer nor the employee shall be liable for any further payment.

For most providers, this is fairly straightforward. For providers of interpreter services, however, it gets trickier. As workcompcentral pointed out, California Code of Regulations (CCR) Section 9792.5.4 specifies that the “only dispute is the amount of payment” when:

1. The services in question were authorized by the claims administrator, and
2. There is an applicable fee schedule for the services in question
   

Point #2 is what complicates matters for interpreters.

Despite the fact that Senate Bill 863 requires the DWC to establish an official interpreter fee schedule, no such fee schedule exists. Interpreter services — despite being necessary for the treatment of some injured workers — are left out of the state’s Official Medical Fee Schedule (OMFS).

It’s understandable, then, that a provider of interpreter services might conclude that Second Review and Independent Bill Review (IBR) are inapplicable to their disputes in the absence of a fee schedule — and that liens, generally reserved for “threshold issues” like contested liability, are the interpreter’s appropriate recourse.

The appellate court, however, didn’t see it that way.

Another regulation, CCR §9795.3, establishes “reasonable” fees for interpreter services. The court ruled that CCR §9795.3, therefore, serves as a “fee schedule” for the purpose of second review appeals. Because DFS failed to request a Second Review, Meadowbrook could, in essence, take back its previous authorization and renege on payment quite legally.

Welcome to the Club of Inequity

Per this ruling, interpreters are now welcomed into the club of providers who must always, always submit a second review appeal when the claims administrator improperly denies reimbursement. Thanks to the appellate court’s reasoning that CCR §9795.3 constitutes a fee schedule, interpreters join other providers who also shoulder all of the burdens of monitoring and appealing for correct payment.

Welcome, interpreters, to an appeals process that requires Olympic-level jumping of increasingly higher hurdles.

This is a system where any minor lapse or oversight by a provider could mean no payment while claims administrators seemingly suffer no consequences for denying a reimbursement that is due.

However, interpreters should take heart, as it’s not all bad news. Our provider clients have recovered over $43 million in additional payments from second review appeals while protecting their right to escalate further, if necessary.

Providers can be sure that claims administrators will eventually underpay, knowingly or in genuine error. It’s an unfortunate reality of workers’ comp, one that drives providers away from the industry. Be sure your office is ready to protect your revenue.

DaisyBill makes submitting second review appeals easy and instant. Our Billing Software makes it clear when claims administrators pay less than fee schedule, and alerts your office when claims administrators fail to timely comply with second review appeals. We’ve got your back — schedule a free demonstration today.

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