Employers Holdings set a shameful new standard of indifference with regard to promptly and correctly reimbursing providers. The insurer incorrectly denied payment, disregarded Independent Bill Review (IBR), and only acknowledged culpability after DaisyBill filed an audit complaint with state authorities.

Employers’ conduct is an example of the brazenness that payers can display when no one is responsible for enforcing the rules.

Open & Shut IBR

The provider originally billed Medical-Legal code ML101 for a follow-up Medical-Legal evaluation. Employers denied payment on the grounds that the provider did not conduct an initial Medical-Legal evaluation, and therefore could not bill for a follow-up.

However, the original bill included documentation of the initial evaluation, which occurred less than six months prior to the follow-up evaluation in question, and which Employers processed and paid.

Following Employers’ initial denial, the provider promptly submitted a Second Review appeal within the 90-day window to dispute incorrect reimbursement. Even given a second chance to get it right, Employers again denied payment. The provider had no choice but to pay $180 to file an IBR with Maximus, the private entity to which the Division of Workers’ Compensation (DWC) delegates IBR.

Maximus ruled in favor of the provider, asserting in their Final Determination letter:

Criteria for ML101: Follow-up Medical-Legal Evaluation. Limited to a follow-up medical-legal evaluation by a physician which occurs within nine months of the date on which the prior medical-legal evaluation was performed.

...Submitted QME report meets the definition of ML101. Follow-up medical-legal evaluation occurred within nine (9) months of the prior medical-legal evaluation. ML101-95 Overturned.
[emphasis Maximus’]

Unfortunately, Employers’ obstinance didn’t end there.

Passive Noncompliance

When Maximus rules to overturn an incorrect payment, the claims administrator has 45 days from the date of the Final Determination letter to remit what they owe to the provider.

Maximus determined that Employers owed the provider an additional $1,812.50, plus $180 for the IBR filing fee the provider paid to initiate IBR. However, 54 days from the date of the Final Determination letter, Employers had yet to respond in any way.

On behalf of the provider, a DaisyBill agent reached out to Employers and asked to speak with the claims adjuster. Over a series of phone calls, a farce ensued in which:

• An Employers representative provided what they claimed was the adjuster's phone number, but which directed our agent to Employers’ main line instead.
• Our agent asked to be transferred to the adjuster, at which point Employers transferred our agent to Employers’ bill review instead.
• The Employers representative claimed they were unable to provide the adjuster's direct number, and finally transferred our agent to the adjuster’s voicemail.

After receiving no response from the adjuster for several days, we reached out again. For a second time, Employers refused to provide a direct number to the adjuster, and transferred our agent to the adjuster’s voicemail. For good measure, our agent also sent an email to Employers requesting the status of the payment.

We heard nothing but crickets.

A full 68 calendar days after state authorities determined that Employers owed additional reimbursement to the provider, we exercised the only remaining option: filing an audit complaint against Employers. 

Still, our agents kept reaching out. Countless minutes on hold, multiple transfers, and multiple voicemails had no effect. Even when Employers answered the phone, the result was inevitably the same: a transfer to the adjuster’s voicemail, which is apparently checked only when certain celestial bodies align.

At one point, Employers simply stopped answering; no hold, no voicemail, just an endless ringing into the void of passive noncompliance.

(Literally) Too Little, Too Late From Employers

Finally, 152 days from the date of Maximus’ first IBR ruling, Employers issued payment for the first incorrectly denied Medical-Legal follow-up evaluation. The payment was 107 days late, and the payment did not include restoration of the $180 IBR filing fee the provider was forced to pay to file the IBR. Nor did the payment include money owed for Penalty and Interest (P&I), the punitive charges the DWC applies for late payment.

As of this writing, simply to secure proper reimbursement for services rendered, the provider and DaisyBill had to:

1. Submit an original bill
2. Submit a Second Review appeal
3. Pay $180 and file an IBR
4. Prevail in IBR
5. Submit an audit complaint
6. Expend valuable time and practice resources hounding Employers’ unresponsive team

As of this writing, Employers still owes this provider:

• $180 in IBR filing fees
• Penalty & Interest
• An apology

Employers continues to engage in this war of payment attrition, forcing this provider to go to expensive, unnecessary, and time-wasting measures. This begs the question: whom does this benefit? Certainly not injured workers, employers, or providers. Ultimately, this behavior doesn’t even benefit Employers, whose disregard for the rules leaves the insurer owing more than the provider initially billed.

Employers’ lackadaisical attitude towards compliance can only hurt them, and the workers’ compensation system as a whole.

DaisyBill has your back. We stay on top of claims administrators to ensure correct payment, so you can focus on treatment. Reach out by phone or email, and see how we can help.

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