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.

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