As daisyNews reported yesterday, Helmsman Management Services, LLC attempted to claw back payment from a California provider for plainly bogus reasons. We debunked those reasons in our last article—but Helmsman’s claims management mess doesn’t stop there.

In addition to losing track of an NBC Universal injury claim and flunking basic workers’ comp knowledge (Fact: that there are no refunds in California), Helmsman also shortchanged the doctor by using an outdated version of the state fee schedule.

That’s right—Helmsman actually owes more money to the doctor for the bill that Helmsman tried to get the doctor to refund. On top of that, Helmsman failed to respond to the Second Review appeal that the doctor sent to dispute Helmsman’s incorrect payment.

NBC Universal should pay attention. Here is what Helmsman did to the doctor who treated an NBC injured worker:

1.  Underpaid the doctor by applying a lower, outdated fee schedule rate.
2.  Ignored the doctor’s Second Review appeal disputing the incorrect reimbursement.
3.  Demanded a refund based on a bogus claim that Helmsman wasn’t responsible for the injury.

This Helmsman payment fiasco is a prime example of the daily whack-a-mole California doctors endure—constantly fending off new tactics from claims administrators trying to dodge proper reimbursement.

Helmsman Actually Owes the Doctor More Money

In addition to losing track of its injury claims and failing to grasp basic facts about refunds, Helmsman’s payment system, apparently stuck in a time warp, failed to reimburse the doctor at the current fee schedule rates.

As a result, Helmsman underpaid the doctor by $2.86 for the treatment provided to the injured worker. Helmsman's explanation of review (EOR) is below.

Sure, $2.86 isn’t going to break the bank. But:

• It’s reimbursement Helmsman rightfully owes the doctor, and
• The doctor had to send a Second Review appeal to obtain the additional reimbursement—a further expenditure of practice time and resources.

As if Helmsman needed to add further torment to this tale, the TPA did not bother to respond to the Second Review appeal.

Under California law, claims administrators have 14 calendar days to respond to a Second Review appeal. Helmsman’s response was due on April 17—but the provider heard nothing back.

Audit Complaint Sent to CA DWC Black Hole

Since Helmsman failed to comply with California law and timely respond to the provider’s appeal, daisyBill filed a formal Audit Complaint (below) with the California Division of Workers’ Compensation (CA DWC) — not that we expect the inert agency to take meaningful action.

Sadly, the CA DWC routinely watches abuse like this unfold, yet does nothing.

With no incentive to comply, TPAs like Helmsman act accordingly and ignore California laws meant to protect doctors who care for injured workers.

Many providers, understandably, refuse to care for injured workers.

NBC Universal might want to rethink who manages its employees’ injury claims. A claims administrator who can’t follow the fee schedule, ignores payment laws and mistakenly demands refunds may not be the best choice to handle their injured workers’ care.

The payer may not know the fee schedule—but daisyBill does. Send 100% accurate e-bills every time. Click below to see how we make life easier for providers:

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