In a perfect example of California’s failing Independent Bill Review (IBR) process, Maximus (California’s designated IBR organization) abandoned all semblance of lawfulness and logic to deny a physician reimbursement for a Medical-Legal evaluation requiring a language interpreter.

Maximus denied reimbursement for modifier -93 for an evaluation requiring an interpreter, on the grounds that the physician did not justify modifier -93 with an adequate description of “the circumstance” and “increased time required” for the evaluation.

Under penalty of perjury, the report submitted by the evaluator documented the “circumstance,” i.e. the presence of an interpreter. For countless bills, the presence of an interpreter has been understood to inherently indicate the “circumstance” of evaluating a patient who speaks a different language than the evaluator.

Maximus is correct that the evaluator did not document the “additional time” required, because to make that calculation, the evaluator would need to perform two evaluations, one with the interpreter and one without — the latter being impossible since the patient does not speak the language of the physician…hence the interpreter.

If this sounds like a parody of IBR, be advised: this was an actual IBR decision made by an alleged California workers’ comp expert. Unfortunately, the ‘experts’ at Maximus represent both the State of California and the tragic state of California’s crumbling workers’ comp reimbursement system.

Med-Legal Evaluation Required an Interpreter

In this case, a Spanish-language interpreter was present during a Qualified Medical Evaluator (QME) Follow-up Medical-Legal Evaluation (ML202), to assist the QME in communicating with the injured worker. Dutifully, the QME documented in the ML202 report the presence of the interpreter as follows:

“Please note that -93 modifier has been added in this case because the services of a certified Spanish interpreter has been utilized throughout the interview and physical examination portion of this report.”

And yet, Berkley Net Underwriters, LLC, denied the increased reimbursement for modifier -93.

Appropriately, the QME submitted a Second Review appeal to dispute the denied reimbursement. Again, Berkley denied payment for modifier -93, forcing the QME to spend $180 and file for IBR with Maximus.

Maximus Denies -93 Interpreter Reimbursement

Medical-Legal evaluators, take a seat for this one: Maximus denied reimbursement to the evaluator for the presence of an interpreter.

‘Miscarriage of justice’ does not begin to describe Maximus’ decision, though ‘miscarriage of common sense’ comes close. Maximus noted in their decision (below) that the QME “indicated an interpreter was present” in the evaluation report, but denied reimbursement because there was “no description of the circumstance, or the increased time required for the examination as a result of having an interpreter present.”

Medical-Legal evaluators, be advised: You must be incredibly clear in all evaluation reports about the circumstances and additional time expended to justify the use of modifier -93.

For additional reimbursement per modifier -93 when an interpreter is present for a Medical-Legal evaluation, perhaps evaluators should consider adding to their reports the following justification (under penalty of perjury):

Description of Circumstances Requiring -93 modifier: An interpreter was needed because the injured worker spoke a language different from the language spoken by the evaluator. These circumstances dictate that when the injured worker spoke words, the evaluator could not understand the injured worker’s words, and vice-versa.

Increased time required due to presence of interpreter: The need for an interpreter increased the time necessary for the evaluation by the amount of time it takes to communicate in two separate languages as enabled by the presence of the interpreter.

Because that’s how interpreting works.

California Medical-Legal evaluators, consider yourselves warned!

Maximus may not always have a firm grasp on the rules, but we do. daisyBill makes appealing incorrect payments easier, faster, better. Learn what daisyBill can do for your practice:

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