California regulations mandate that when Independent Bill Review (IBR) overturns a claims administrator’s incorrect bill denial or adjustment and finds in favor of the provider, the claims administrator must reimburse the provider for the $195 IBR filing fee, in addition to the disputed amount owed.

Unfortunately certain claims administrators, including TriStar Risk Management, Protective Insurance, and Acclamation Insurance ignore this important rule, forcing providers to go to preposterous lengths to recover the full amount due.

A Reimbursement Nightmare

This blog has detailed the Kafkaesque reimbursement ordeal forced upon providers when a claims administrator fails to properly reimburse the provider. These providers follow the established appeal process to recover the correct payment, which includes submitting the following:

• A complete, compliant original bill as mandated by California law,
• A timely second review appeal requesting a correct reimbursement,
• A timely request for IBR, including all the required documentation, and
• $195 IBR filing fee paid to Maximus Federal Services

Once Maximus makes the IBR decision in the provider’s favor, the claims administrator owes the provider both the corrected reimbursement AND the $195 filing fee. Yet, after all the above effort, providers regularly find that claims administrators refuse to remit the disputed amount owed and/or the $195 filing fee.

Below are examples of such cases, complete with exact timelines detailing providers’ Sisyphean struggle to recover their $195 IBR fee. Whether these claims administrators and their respective adjusters are acting out of defiance, sheer ignorance of the law, or some combination of both, this is unacceptable.

Claims administrators must meet a higher standard of compliance; ie, the bare minimum.

Tristar Risk Management

• 6/12/18: Maximus IBR overturns TriStar denial.
• 7/27/18: Due date for reimbursement of disputed amount and IBR filing fee.
• 7/30/18: DaisyBill legal counsel speaks to Tristar’s bill review firm, MeData, whose representative confirmed knowledge of the IBR decision and Tristar’s obligation to pay.
• 8/15/18: DaisyBill Compliance Team leaves voicemail with TriStar’s adjuster, requesting payment.
• 8/22/18: Compliance Team leaves second voicemail with adjuster, requesting payment.
• 8/29/18: Compliance Team reaches adjuster by phone and emails IBR decision to adjuster, who made assurances that payment would be remitted.
• 9/12/18: Compliance Team sends email to adjuster, again requesting payment.
• 9/18/18: Compliance Team sends email to adjuster, again requesting payment.
• 9/26/18: Compliance Team reaches adjuster by phone, who indicated no response from MeData following a request for information.

As of this writing, TriStar has yet to remit reimbursement for the $195 IBR filing fee.

Protective Insurance

• 7/9/18: Maximus IBR overturns Protective denial.
• 8/23/18: Due date for reimbursement of disputed amount and IBR filing fee.
• 8/29/18: Compliance Team leaves voicemail with Protective’s adjuster, requesting payment.
• 8/30/18: Compliance Team leaves second voicemail left with adjuster, requesting payment.
• 8/31/18: Compliance Team reaches adjuster by phone. Adjuster was completely unaware of the IBR process and its requirements.
• 9/4/18: Compliance Team emails IBR decision to adjuster.
• 9/6/18: Compliance Team sends second email to adjuster, requesting payment.
• 9/10/18: Compliance Team leaves third voicemail with adjuster, requesting payment.
• 9/12/18: Compliance Team reaches adjuster by phone. Adjuster reported a need to seek legal advice before complying with IBR decision.
• 9/18/18: Compliance Team sends third email to adjuster, requesting payment.
• 9/26/18: Compliance Team sends fourth email to adjuster, requesting payment.

As of this writing, Protective has remitted neither the disputed amount, nor reimbursement for the $195 IBR filing fee.

Acclamation Insurance Management Services

• 7/27/18: Maximus IBR overturns Acclamation denial.
• 9/10/18: Due date for reimbursement of disputed amount and IBR filing fee.
• 9/12/18: Compliance Team leaves voicemail with adjuster, requesting payment.
• 9/14/18: Adjuster returns phone call; adjuster unaware of legal duty to return filing fee, or of the difference between Independent Bill Review and Independent Medical Review, a separate process for authorization disputes. Compliance Team faxes IBR decision to adjuster.
• 9/18/18: Compliance Team reaches adjuster by phone; adjuster continued to struggle with IBR/IMR distinction, asserted that payment should be remitted to Maximus, not the provider.
• 9/20/18: Adjuster contacts Compliance Team by phone, claims that payment of IBR filing fee is forthcoming

As of this writing, Acclamation has agreed to remit the disputed amount owed, along with reimbursement for the $195 IBR filing fee.

Voicemails, emails, and faxes pile up as providers and their agents work overtime just to collect what should never have been denied in the first place. This is not only unjust and insulting, it’s unsustainable. Providers cannot treat injured workers if obtaining just compensation is this absurdly difficult.

This non-compliance, and the Sisyphean efforts providers must make to recover funds, has got to stop.  

 When the claims admin doesn’t play by the rules, DaisyBill has your back. Our Billing Software includes tools for second review appeals, and access to our IBR Decision Library. Schedule a free demonstration today.

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