We asked our readers to submit their most vital California workers’ comp questions for a live Q&A webinar. They did not disappoint!
If you missed it, below is a brief review — plus access to stream the recording and download the slides!
We’d like to thank everyone who submitted questions, and provided feedback after the webinar.
A few of our favorite responses:
“Honest, straight-forward approach.”
“Very explicit detailed responses to questions asked.”
“DaisyBill is fighting for and with providers in an industry where insurance carriers seem to follow a clear strategy of avoiding making payments — a broken system that would be even worse without DaisyBill.”
Below are a few of the questions we tackled in each category.
“What is a DWC Audit Complaint?”
“How do you do this?”
“Will it work for both bill review and the claims administrator itself?”
We reviewed the complaint system established by the California Division of Workers’ Compensation (DWC) for providers to report noncompliant behavior by payers.
While consequences for bad behavior are inadequate (read: practically nonexistent), regularly submitting complaints is vital to making providers’ voices heard.
Individually, providers can only do so much. But collectively, each action helps establish patterns of noncompliance, identify the worst offenders, and call the DWC’s attention to systemic issues in our industry.
Second Review & Independent Bill Review (IBR)
“When a bill is sent electronically, can the SBR be in paper form?”
“What is the best way to submit an appeal and assure it is received by the claims administrator? Should we be sending them certified?”
“We receive many denials for No prior Authorization even when the authorization is attached to the bill. Is the SBR Form required for resubmission?”
“What is IBR?”
Second Review appeals are the first line of defense against incorrect denials or adjustments of providers’ bills. Claims administrators will send incorrect payments and denials disturbingly often. Second Review is therefore vital to protecting any practice’s overall revenue.
To date, DaisyBill clients have recovered over $67,000,000 via Second Review.
When a Second Review fails to result in correct reimbursement, it may be necessary to request IBR. By appealing to the state and its designated Independent Bill Review Organization (IBRO), providers can seek a third-party ruling on disputes.
Authorization & Utilization Review (UR)
“How many days does the claims administrator have to answer an RFA?”
“If the claims administrator fails to respond to the RFA, is the proposed treatment automatically authorized?”
“Do you need to request RFA for interpretation services?”
“If the claims administrator issues the UR decision, why does the provider have to send it with the bill?”
Obtaining authorization is a fraught process — and claims administrators like it that way. That acknowledged, adhering to the authorization and UR rules is worth the time and effort for providers. Authorization guarantees payment!
Bill Submission Documentation
“For Dr. visits in the office, what documentation is required to send with the claim?”
“Can bill review request invoices for DME that have a value in the fee schedule?”
“Why is there no payment for the PR-2 unless the provider is the primary-care physician?”
“Why are some claims administrators still not accepting electronic claims?”
Always remember: the system defaults to the payer’s advantage.
If the provider makes any mistakes in correctly submitting the bill and supporting documentation, the claims administrator has an opportunity to deny proper reimbursement. Know the rules, and avoid putting your office in a position to lose out!
Explanation of Review (EOR)
“Why do some companies send the payment check with the patient's name without an EOB?”
“What is the time frame to send an EOR? If it exceeds the time frame, can we file an Audit Complaint?”
In California, the claims administrator is required by law to respond to provider bills according to strict guidelines.
For providers, it’s crucial to review all EORs, and submit Second Review appeals in the event of incorrect payment, downcoding, or other payer errors. Electronic billing makes this much, much easier, as payers must respond electronically to all electronic bills.
For (very) detailed answers to the questions above (and many more), watch the webinar! It’s available in our Webinar Library, a free resource for anyone who wants to learn more and bill better.
Note: due to the overwhelming number of excellent questions we received, we will host separate webinars devoted to:
- Medical-Legal billing
- Medical Provider Networks (MPN)
- Discount reimbursement contracts
If you submitted questions on any of the topics above, stay tuned! You’ll get an invitation to those upcoming webinars soon. It is our mission to inform and empower providers, so we can create a better workers’ comp system for all stakeholders.