In light of the all-new Medical-Legal Fee Schedule (MLFS) for California workers’ comp, we debuted a new tool to help providers. Our MLFS “Report Cards” analyze payer compliance (or lack thereof) with the new fee schedule, highlight incorrect denial reasoning, and offer language providers can use for Second Review appeals.
In this post, we explain how to use the MLFS Report Cards to help ensure your practice is compensated correctly.
Provider Warning: Due to the lack of consequences for failing to adhere to billing regulations, some claims administrators (and their bill reviews) continue to deny the new MLFS billing codes as invalid or non-existent. In these instances, you must promptly file a Second Review appeal; our Report Cards provide suggested language.
Sedgwick: Example MLFS Report Card
Below is an example of an MLFS Report Card for Sedgwick:
Sedgwick incorrectly denied payment for ML204, a valid medical-legal code. The reason Sedgwick provided for denying payment is that ML204 is “not considered a valid reimbursable code.” Date of Service: 04/09/2021
MLFS Code(s) |
ML204 - Fees for Medical-Legal Testimony |
MLFS Grade |
F |
Claims Administrator |
Sedgwick Claims Management Services |
Bill Review Vendor |
Sedgwick CMS National Bill Review |
Employer |
Orange County Zone |
EOR Adjustment Reason |
561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code. |
Second Review Reason to Dispute Incorrect Reimbursement |
Claims administrator incorrectly denied reimbursement. Per CCR §9795, if a deposition is cancelled fewer than 8 calendar days before the scheduled deposition date, the physician shall be paid a minimum of one hour for the scheduled deposition. ML204 payment due: $455.00. In addition to payment, penalties and interest are now due. |
How to Appeal Incorrect Med-Legal Reimbursements
If you suspect that your bill for Medical-Legal services was improperly denied or adjusted:
Step 1: Navigate to the MLFS Report Card homepage.
Step 2: Browse the list of report cards. Look for cases involving the same...
- Billing code and
- EOR Adjustment Reason Code
In the example above, Sedgwick incorrectly denied code ML204 for Medical-Legal Testimony. The EOR Adjustment Reason Code given by Sedgwick:
561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code
Step 3: Once you locate an applicable Report Card, copy the Second Review Reason to Dispute Incorrect Reimbursement. In this example, the language would be:
Claims administrator incorrectly denied reimbursement. Per CCR §9795, if a deposition is cancelled fewer than 8 calendar days before the scheduled deposition date, the physician shall be paid a minimum of one hour for the scheduled deposition. ML204 payment due: $XXX.XX. In addition to payment, penalties and interest are now due.
Step 4: Submit a Second Review appeal within 90 days of receiving the EOR, using the language copied from the Second Review Reason to Dispute Incorrect Reimbursement.
Provider Warning: Failure to timely submit the Second Review appeal will result in loss of the remaining reimbursement due. It’s a perfect example of how rigged the system is against providers; when the claims administrator fails to properly reimburse, the responsibility for appealing in time is on you, or else the claims administrator keeps your revenue.
The Consequences of No Consequences
As Sedwick demonstrates in the example above, some claims administrators and (the bill reviews vendors hired by the claims administrators) have not updated their systems to recognize the new MLFS codes. This, of course, has a direct connection to the fact that claims administrators face little repercussions for non-compliance with billing and payment regulations.
Undoubtedly, some physicians are not appealing even the most blatantly invalid denials, which results in savings for the payer. While we cannot accuse any claims administrator of knowingly keeping their systems behind the times, we can point out that payers have little motivation to do otherwise.
Therefore, it’s up to providers to demand compliance.
Below is a list of claims administrators who — so far — continue to deny the new MLFS codes as invalid, simply because their systems are apparently stuck in 2020:
- AIG Claims, Inc.
- Farmers Insurance
- AmTrust North America
- Sedgwick
- Next Level Administrators
Common EOR adjustment reason codes used by the payers above to improperly deny the new MLFS codes include (but are not limited to):
Adjustment Reasoning Code |
Description |
|
2 (AIG Claims)
|
This charge will be re-evaluated upon receipt of the proper procedure codes or procedure code/modifier combination as listed in the fee schedule. |
|
270 (Farmers, AmTrust)
|
No allowance has been recommended for this procedure/service/supply. |
|
561 (Sedgwick)
|
The service(s) on this claim have been denied because the provider billed using a procedure code that is not in the fee schedule |
|
G3 (Next Level)
|
The Official Medical Fee Schedule does not list this code. No Payment is being made at this time. Please resubmit your claim with the OMFS code(s) that best describe the service(s) provided and your supporting documentation. |
If your bill for Medical-Legal services is denied or adjusted with any of the above reasoning codes, it is likely the claims administrator is in the wrong.
Together, Medical-Legal physicians can keep the pressure on payers to get their act together. Always appeal incorrect denials or adjustments, both for your own revenue and for the overall integrity of the workers’ comp system.
