Gallagher Bassett Plays IBR Chicken With QME

Gallagher Bassett Plays IBR Chicken With QME

Gallagher Bassett seemingly tried its hand at the game of IBR Chicken, forcing a Qualified Medical Evaluator (QME) to waste time, money, and resources on a needless dispute — before finally backing down and paying up.

For those unfamiliar with IBR Chicken, it’s when a claims administrator’s repeated payment denials seem so absurd that it can feel less like a mistake and more like a strategy — especially when the claims administrator changes their mind and agrees to pay only after the provider requests Independent Bill Review (IBR).

Of course, we can’t definitively say what level of bill review incompetence is too extreme to be believable.

But the fact is that in a payment dispute, if the provider drops the ball at any point in the arduous appeals process, the claims administrator wins by default (and they know it).

In this case Gallagher Bassett somehow had the audacity to cry fowl, indignant that daisyCollect took the dispute to the Division of Workers’ Compensation (DWC) instead of reaching out privately to plead for reimbursement. Details below.

Gallagher Bassett Denies QME Bill

California’s Medical-Legal Fee Schedule (MLFS) mandates payment for a missed Medical-Legal appointment, billed with code ML200.

On April 3rd, 2023, an injured worker failed to appear for a scheduled Medical-Legal evaluation. On April 6th, the Qualified Medical Evaluator (QME) billed Gallagher Bassett. The QME included with the bill submission the attorney letter requesting the evaluation.

Yet Gallagher Bassett denied payment for the missed appointment, citing a bevy of nonsensical reasons including:

  • “CLAIM/SERVICE LACKS INFORMATION NEEDED FOR ADJUDICATION.” (The injured worker didn’t show up for a scheduled appointment. What more information is necessary?)
  • “The charge exceeds the Official Medical Fee Schedule allowance.” (The OMFS does not apply, since this is a Medical-Legal bill. Seems like something a professional bill reviewer would know).
  • “We cannot review this service without necessary documentation.” (The bill submission included a copy of the attorney request for the scheduled evaluation, as well as all other required documentation).
  • The service was not a “medical necessity.” (Correct, like literally every Medical-Legal service.) 
  • Payment denied based on “Workers’ Compensation jurisdictional regulations or payment policies.” (Ok now you’re not even trying.)

Proceeding under the assumption that this was all just a big misunderstanding, daisyCollect submitted a Second Review appeal on the QME’s behalf.

As usual, we included all the pertinent facts, documents, a helpful explanation of why the denial was incorrect, and a clear statement of intent to pursue IBR if necessary.

QMEs, feel free to use this appeal language in a similar situation:

Service incorrectly denied as non-compensable. Per CCR §9795, ML200 Missed Appointment is reimbursable when the injured worker fails to appear for the evaluation appointment. Reimbursement is due for this missed appointment. The attached letter serves as a formal written objection and notice of non-compliant EOR. An IBR will be filed upon failure to properly reimburse ML200.”

Gallagher Bassett’s Second (Review) Chance

Given another chance to correctly adjudicate a bill with a single procedure code on it — one of seven in the entire MLFS — the good folks at Gallagher Bassett pressed forward to retain the QME’s reimbursement.

The TPA denied payment for the Second Review, citing the same deeply silly reasoning.

With no other choice, daisyCollect paid the $180 fee and filed a request for IBR. The reasoning presented to the state was clear and straightforward — much like the original bill, the Second Review appeal, and the MLFS with regard to missed appointments:

Final & Initial EORs [Explanations of Review] incorrectly denied reimbursement citing insufficient documentation. Per CCR §9795, ML200 Missed Appointment is reimbursable when the injured worker fails to appear for the evaluation appointment. Reimbursement is due for ML200.

Gallagher Bassett Chickens Out

Finally, on May 5th, a Gallagher Bassett Resolution Associate acknowledged the TPA’s “oversight” and assured daisyCollect that payment would be forthcoming (email below).

Almost unbelievably (but entirely believably), the Associate seemed genuinely miffed that we requested IBR, claiming that “A phone call would have resolved this.”

Claims administrators make mistakes, right? We’re all human! If only there was some way for a provider to reach out to a claims administrator and point out a mistake before racing to IBR! Like a second opportunity to review the bill…we could even call it “Second Review!”

So we’re clear, filing for IBR is not the ideal billing protocol for a provider to obtain correct reimbursement.

It is costly in time, effort, and administrative resources. Most of the time, it results only in the provider receiving the amount initially billed, maybe the $180 IBR filing fee if they’re lucky, and almost never the mandated penalty and interest payments.

daisyBill, and every provider in California, should have a way to avoid unnecessary IBR. And we can think of one — for claims administrators to timely and correctly pay providers’ bills at the first (or second) opportunity.

Better yet, when claims administrators fail to properly pay a bill and create needless disputes, there should be real consequences. That alone would preclude many an IBR dispute, and save everyone a great deal of time. But as we’ve repeatedly demonstrated, IBR Chicken is a game from which claims administrators continue to profit.

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