2021 Med-Legal Fee Schedule Changes -- Join us for a free webinar on April 15 at 1pm PDT
ESIS & ABM Industries - IBR Hall of Shame

ESIS & ABM Industries - IBR Hall of Shame

We continue to look at the misbehavior of ESIS, which yesterday entered the IBR Hall of Shame for its deplorable treatment of a provider who prevailed in two Independent Bill Reviews (IBRs). This article goes into the gory details and infuriating sequence of (non)communications. For background, see Part 1: Is ESIS Gaming the California Workers' Comp System?

In short, after the provider submitted IBRs, ESIS eventually correctly reimbursed the provider for the disputed amounts. Except the two bill payments sent to the provider did not include reimbursement of the two $180 IBR fees that the provider paid to file the IBRs with Maximus. Below, we document the fruitless, infuriating, and numerous voicemails and emails (18 attempts and counting) which we have so far endured to try to get ESIS to verify payment of the two IBR fees owed. That ESIS’ systems seem unable to cope with such a simple request should give pause to the employers who use ESIS’ services.

The injured worker was employed by ABM Industries, Inc. which is a self-insured California employer that uses ESIS as its Third Party Administrator (TPA). For two separate evaluations of an ABM-employed injured worker, ESIS incorrectly denied reimbursement for the authorized services.

ESIS Fails to Reimburse the Provider $180 IBR Fee (Twice)

In both cases, Maximus ruled against ESIS and awarded payment to the provider. Labor Code 9792.5.14. directs ESIS to reimburse the provider the $180 filing fee when the claims administrator’s bill review decision is overturned by IBR. The law is clear. Yet, the reality is that claims administrators ignore the law with impunity.

Below, we share the extensive, and so-far Sisyphean, efforts made by DaisyBill to contact ESIS and ascertain the status of the $180 fees due to the provider.  Note: ABM Industries should pay attention to the way in which ESIS manages simple phone calls from providers who treat ABM’s injured employees -- and question whether ESIS is treating ABM’s injured employees in a similarly dismissive fashion.

Bill #1 - ESIS Denied Second Review Appeal 2/26/2020

3/12/2020 - Provider Files IBR with Maximus 

IBR Service/Good Code in Dispute: ML102-93 Denied
Reason for Disputing Denial: Second Review EOR indicates this bill was denied for compensability which is not a valid reason to deny a medical-legal bill. This medical-legal exam was provided at the request of the parties. All submissions of the bill included copies of the requesting letters from both parties - notably one being the Law Offices of Bradford and Barthel who represents the employer/claims administrator. Previous IBR decisions have been overturned for identical issues. See CB17-0001265.

6/1/2020 - ESIS Payment Date $687.50

7/24/2020 - Maximus Decision Date

Maximus Decision: The Claims Administrator’s determination is reversed and the Claim Administrator owes the Provider additional reimbursement of $180.00 for the review cost and $687.50 in additional reimbursement for a total of $867.50.

Bill #2 - ESIS Denied Second Review Appeal 6/14/2020

6/26/2020 - Provider Files IBR with Maximus 

IBR Service/Good Code in Dispute: ML106 Denied
Reason for Disputing Denial: Final EOR incorrectly denied Second Review submission as a duplicate. This was a supplemental Qualified Medical Evaluation. Per defense attorney letter, additional records were provided to Dr. XXXXX and [they were] asked to address them. This supplemental report meets the criteria for payment under ML106.

9/14/2020 - ESIS Payment Date $875.00

10/29/2020 - Maximus Decision Date

Maximus Decision: The Claims Administrator’s determination is reversed and the Claim Administrator owes the Provider additional reimbursement of $180.00 for the review cost and $875.00 in additional reimbursement for a total of $1,055.00

One thing to note regarding IBR fees is that, once an IBR has been filed, it doesn’t matter if a disputed amount was paid before or after Maximus’ determination: if the provider prevails, as in these cases, the provider is owed the $180 that the provider already paid for the IBR filing fee.

Bill

Date

Days Payment Overdue

Action

Action Count

Notes

#1

06/01/2020

0

ESIS issued payment for disputed amount

N/A

ESIS paid disputed amount before Maximus issued the Final Determination Letter.

#1

07/24/2020

0

Maximus issued Overturn decision

N/A

Maximus determined additional reimbursement is warranted.

#1

09/07/2020

0

Due: Additional Revenue $687.50 & $180 IBR Filing Fee

N/A

Additional revenue plus IBR Filing Fee due 45-Days after Maximus Final Determination Letter.

#1

09/10/2020

3

DaisyCollect called ESIS

1st call attempt

No answer.

#1

09/15/2020

8

DaisyCollect called ESIS

1st conversation

Obtained the adjuster name and contact info

#1

09/15/2020

8

DaisyCollect called adjuster

1st voicemail

Called adjuster XXXXXX and left a voicemail requesting the status of the IBR Filing Fee payment.

$180 IBR Filing Fee remains due.

#1

09/29/2020

22

DaisyCollect called adjuster

2nd voicemail

Called adjuster XXXXXX and left a voicemail requesting the status of the IBR Filing Fee payment.

#1

10/07/2020

30

DaisyCollect called adjuster

3rd voicemail

Called adjuster XXXXXX and left a voicemail requesting the status of the IBR Filing Fee payment.

#1

10/14/2020

37

DaisyCollect called ESIS

2nd conversation

Called ESIS a second time to find the contact info for the adjuster’s supervisor. Claims representative was then unable to locate the patient file.

#1

10/22/2020

45

DaisyCollect called adjuster

4th voicemail

Called adjuster XXXXXX and left a voicemail requesting the status of the IBR Filing Fee payment.

#1

11/04/2020

58

DaisyCollect called ESIS

3rd conversation

Spoke with claims representative to obtain contact information for adjuster’s supervisor.

#1

11/04/2020

58

DaisyCollect called adjuster’s supervisor

4th voicemail

Called supervisor XXXXXX, but they did not answer, so left a voicemail requesting the status of the IBR Filing Fee payment.

#1

11/16/2020

70

DaisyCollect called adjuster’s supervisor

5th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

#1

12/01/2020

85

DaisyCollect called adjuster’s supervisor

6th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

#1

12/24/2020

108

DaisyCollect called adjuster’s supervisor

7th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

#1

12/24/2020

108

DaisyCollect called adjuster

8th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

#1

01/06/2021

121

DaisyCollect called adjuster’s supervisor

9th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

#1

01/20/2021

135

DaisyCollect called adjuster’s supervisor

10th voicemail

Left voicemail requesting the status of the IBR Filing Fee payment.

Bill

Date

Days Payment Overdue

Action

Action Count

Notes

#2

09/14/2020

0

ESIS issued payment for disputed amount

N/A

ESIS paid disputed amount before Maximus issued Final Determination Letter.

#2

10/29/2020

0

Maximus issued Overturn decision

N/A

Maximus determined additional reimbursement is warranted.

#2

12/13/2020

0

Additional Revenue $875.00 & $180 IBR Filing Fee due

N/A

Additional revenue plus IBR Filing Fee due 45-Days after Maximus Final Determination Letter.

#2

12/17/2020

4

DaisyCollect called adjuster’s supervisor

1st voicemail

Left message with adjuster's supervisor XXXXXX requesting the the status of the IBR Filing Fee payment.

$180 IBR Filing Fee remains due.

#2

01/06/2021

24

DaisyCollect called adjuster’s supervisor

2nd voicemail

Left message requesting the status of this payment.

#2

01/21/2021

39

DaisyCollect called adjuster’s supervisor

3rd voicemail

Left message requesting the status of this payment.


Become a DaisyBiller to benefit (and profit) from our expertise, our data, and our mission to get providers paid in the workers’ comp system.

Schedule a Demo

Subscribe to DaisyNews

Recent Posts

Popular Topics

California (486) claims administrators Billing Education News Updates Fee Schedule OMFS Second Review e-Billing California DWC RFA medical-legal
New York (5) CMS 1500 Billing Education Electronic Billing e-Billing
intercom_chat_bubble_icon