California law requires payers to respond to a provider’s Second Review appeal within 14 days. If a payer fails to respond, no regulation prohibits the provider from submitting a duplicate; however, the provider should never send a duplicate Second Review appeal.

Recent determinations from the California Division of Workers’ Compensation (CA DWC) indicate that submitting a duplicate Second Review appeal will eliminate the provider’s ability to pursue Independent Bill Review (IBR).

Instead, the CA DWC instructs providers that when a payer ignores an appeal, they should file a petition with the Workers’ Compensation Appeals Board (WCAB) to compel the payer to respond to the Second Review appeal.

All California payers (and providers), pay attention!

A “Second Review Snub” is a new tactic available to payers. Think of it as a precursor to “IBR Chicken,” one that can totally preclude independent review from the state. With a Second Review Snub, payers can effectively prevent providers from filing for IBR by taking the following steps:

1. Deny (or reduce) payment for a bill, for any reason (or no reason).
2. Ignore the provider’s Second Review appeal.
3. If (and only if) the provider files a petition with the WCAB, issue a final Explanation of Review (EOR) denying payment.

In the unlikely event the provider survives the snub, IBR Chicken remains available:

4. If the provider pays $195 to request IBR, pay the bill before the state issues a determination. If the provider withdraws the request, the payer does not have to restore the filing fee to the provider.
5. Ignore any penalty and interest owed for failure to pay timely, since the CA DWC has declared those payments “self-executing.”

For payers, adding a Second Review Snub to the standard operating procedure can ensure that even fewer providers will successfully navigate the appeals obstacle course, allowing payers to keep even more of doctors’ revenue.

Both Second Review Snub and IBR Chicken are free to payers. What consequences exist on paper are, historically, rarely enforced.

Under the previous Administrative Director of the CA DWC, the payment system devolved into something farcically payer-friendly. We hope the agency’s new leadership makes consequences for payer non-compliance a top priority. If the payment games continue, providers will keep abandoning California’s workers’ comp system.

Second Review Appeals: One per Bill

A California provider timely and compliantly submitted an original bill to Zurich Insurance North America, which improperly denied correct reimbursement. The provider then sent Zurich a Second Review appeal, which Zurich ignored.

The provider submitted a duplicate Second Review appeal, to which Zurich responded with a final EOR that still refused correct reimbursement. As providers must when a Second Review appeal fails to resolve a payment dispute, the provider ponied up the $195 filing fee and requested IBR from the state.

In response, the provider received the letter below from the CA DWC explaining that the duplicate Second Review submission negated the IBR request, stating (emphases ours):

“It is not appropriate, after the completion of the initial second bill review process, to submit any subsequent duplicate requests for second bill review to the claims administrator.

This application contains more than one Request for Second Bill Review form, DWC Form SBR-1, each with a different date. Because of the multiple requests for second bill review contained in this application, it is not possible to determine whether the application is timely.

Accordingly, this application is not eligible for independent bill review.”

Since Zurich ignored the first appeal and provided a final EOR in response to the appeal resubmission, a reasonable argument could be made that the IBR application was due within 30 days of that final EOR, i.e., the only final EOR the provider received.

However, the letter above is clear: multiple Second Review appeals = no IBR.

daisyBill reminds providers that payment disputes typically default to the payer’s advantage. Missing a deadline, making a mistake on a required form, or (as it turns out) submitting multiple appeals likely results in the payer keeping your revenue.

Submit Second Review appeals in seconds (and automatically track payer responses) with daisyBill. Click to see how:

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