California fails to maintain a workers’ comp environment that’s fair and navigable for providers (you know, the people who treat the injured workers). Prime example: the Division of Workers’ Compensation (DWC) seems chronically incapable of timely conducting Independent Bill Review (IBR), as required by law.

When a provider requests IBR to dispute an incorrect reimbursement, California law requires the DWC to “assign the request to an independent bill reviewer within 30 days.” Yet according to our data, the DWC (you know, the people in charge of enforcing workers’ comp laws) consistently fails to meet that deadline.

Below is a list of 18 pending IBR decisions that daisyCollect doctors are currently waiting (and waiting and waiting) to be resolved. One of these requests has been floating in IBR purgatory since January of this year, and has yet to be assigned by the DWC (to Maximus, the DWC’s IBR proxy) for review.

All 18 of these IBR requests are for reimbursement for Medical-Legal services. And given that the overwhelming percentage of IBR cases are decided in the provider’s favor, in all likelihood, these physicians evaluators are owed the reimbursements in dispute.

The DWC’s lack of adherence to California law is yet another example of how physicians struggle to navigate California workers’ comp’s double-sided regulatory environment, in which the state either ignores or fails to enforce the relatively few paltry laws designed to protect providers.  

DWC’s Consistent Violations

If a claims administrator improperly adjusts or denies payment for services rendered to an injured worker, a provider must first submit a Second Review appeal. If the claims administrator stands by their decision, the provider must pay $180 to request IBR within 30 days of receiving the final Explanation of Review (EOR).

If the provider fails to timely request the IBR, California Labor Code Section 4603.6 mandates that the provider forfeits any additional reimbursement owed:

“If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment.”

By allowing the claims administrator to retain the reimbursement, California penalizes the provider for missing the IBR request deadline.

Yet California never penalizes the claims administrator for failing to properly or timely reimburse the provider. Moreover, §4603.6 also mandates that once a provider requests IBR, the administrative director (of the DWC) must assign the dispute to the “independent bill reviewer,” i.e., Maximus, within 30 days:

“Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative director’s designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.”

But as our IBR data below demonstrate, the DWC often ignores this 30-day assignment requirement. In the example directly below, it took the DWC 202 days to assign the dispute to Maximus.

DWC Ignores Paltry Provider Protection Laws

From the date of IBR assignment by the DWC, California law mandates Maximus must render an IBR decision within 60 days. Essentially, the California legislature allows a maximum of 90 days total for the DWC to resolve payments disputes when a provider requests (and pays for) IBR.  

Except the data clearly demonstrate that IBR cases are rarely resolved in 90 days, due to the DWC’s failure to timely assign disputes.

Imagine a job where your employer repeatedly shorts your paycheck, and you must pay $180 to the state to dispute each incorrect paycheck. Then you wait months and months and months for the state to review your paycheck dispute (despite laws that require a total 90-day dispute process).

Even when the state eventually resolves the dispute in your favor, the only monetary consequence your employer faces is simply paying you the amount owed in the first place.

In addition to failing to timely review your paycheck dispute (as required by law), the state also:

1. Fails to enforce the law that your employer reimburses you the $180 dollar fee you paid to dispute the incorrect paycheck.
2. Fails to enforce legally mandated penalty and interest payments you are owed for the months you went without correct pay.

This hypothetical salary scenario is exactly the struggle providers face in California workers’ comp’s double-sided regulatory environment.

Claims administrators fail to adhere to the law, because the DWC fails to enforce it. Meanwhile, the DWC also violates the law, leaving providers defenseless and unable to collect the correct reimbursement.

Long IBR Process Hurts Providers

The current IBR regulations implemented by the DWC monetarily incentivize claims administrators to play “IBR Chicken” rather than reimburse providers properly for injured workers’ treatment.

The rules of the game are simple: erroneously, knowingly, or just carelessly, claims administrators refuse to pay providers. Then, the claims administrators wait to see if the providers make it through the appeals gauntlet, which culminates in requesting IBR — a heavy undertaking that requires time, administrative resources, and a $180 fee.

Claims administrators know that if the provider slips at any point in this complex appeals process, the provider’s reimbursement is forfeit.

Moreover, the DWC rigs the process against those pugilistic providers intent on disputing incorrect reimbursements all the way to IBR. The DWC allows the claims administrator to circumvent IBR requests by either:

1. Paying the provider the correct amount without consequences after the provider requests IBR (no penalty, no interest, no reimbursement of the $180 IBR fee)
2. Changing the payment denial or adjustment reason after the provider requests IBR to claim a “threshold” issue, which renders the dispute ineligible for IBR.

IBR Chicken is not a hypothetical scenario – it is the real struggle California workers’ comp providers face. The more difficult and unreliable the DWC makes IBR for providers, the less inclined providers are to request it.

IBR Delays Incentivize Abuse

As we’ve shown again and again, claims administrators often pay the disputed amount only after the provider requests IBR, but before Maximus makes a decision.

Why? Because once the provider manages to pay $180 to request IBR, the claims administrator is likely to lose. Since 2018, Maximus has conducted 434 IBRs for daisyCollect clients. Of those disputes:

• Maximus overturned the claims administrator’s denial/adjustment 368 times (85%)
• Maximus upheld the claims administrator’s denial/adjustment 48 times (11%)
• 18 decisions (listed below) are pending as of this writing (4%)

That’s an 85% “win” rate for daisyCollect providers. This leaves us to contend with two critical facts:

• IBR most often vindicates the provider.
• Utilizing IBR is prohibitively difficult for providers, particularly when even the strongest cases take months to resolve.

As implemented by the DWC, the current IBR process financially incentivizes claims administrators to deny payment, because the claims administrator can simply reverse course once the provider pays $180 to request IBR.

In summary, this is the state of California workers’ comp:

1. Injured workers receive authorized treatment from a provider.
2. Claims administrators deny payment for the authorized services.
3. Providers timely pay $180 (and assemble reams of paperwork) to request IBR.
4. Valid IBR requests gather dust waiting for the DWC to assign the dispute to Maximus.
5. The state refuses to enforce penalty and interest laws for unjustly delayed payments.
6. The state refuses to enforce reimbursement of the $180 IBR fee to the provider.

California couldn’t do much better in devising a system to drive doctors away from treating injured workers.

Pending IBR Decisions (Mostly OVERDUE)

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