DaisyBill loves Audit Complaints*. Why? Because Audit Complaints matter. Audit Complaints bring noncompliant claims administrators to the DWC’s attention while simultaneously providing data about improper business practices.

Examining DaisyBill’s data from over a thousand Audit Complaints submitted by DaisyBillers since this past August, we rank the five most frequent pain points that affect providers.

Total Audit Complaints by Category

Two weeks ago, I covered The #1 Reason for Audit Complaints: Overdue Processing. Overdue Processing occurs when a claims administrator fails to respond to a bill within the mandated timeframe.

This week, I’ll break down the numbers for Incorrect Denials, a problem so prevalent that it prompted our users to file over 300 Audit Complaints to the Department of Workers’ Compensation (DWC).

The three most common reasons providers file Audit Complaints citing Incorrect Denial are:

1. Request for Second Review denied as duplicate bill submission.
2. Denial incorrectly cites missing documentation.
3. Denial incorrectly cites lack of authorization for authorized services.

First, every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500. Accordingly, these Second Reviews are clearly NOT duplicate submissions.  

Rather than denying the request for Second Review as a duplicate submission, a claims administrator must respond with a Final EOR and address the disputed payment detailed in the Second Review.

Second, if a claims administrator does not receive the necessary documentation to review a bill, both Labor Code § 4603.3 and The DWC Medical Billing and Payment Guide require the EOR to cite the specific documentation which is missing. A generic denial based on missing documentation is not compliant.

Further, every bill history in DaisyBill displays BOTH the documentation included with a bill submission and a verified receipt that the claims administrator received the documentation.  

Third, denying authorized services as unauthorized is a suspect tactic by claims administrators to delay payment, burdening providers with the additional submission of the DWC Form SBR-1 to prove authorization prior to receiving payment for services rendered.  

Here at DaisyBill, we find Incorrect Denials incredibly frustrating.  These unjustified denials indicate either:

• Claims administrators are not paying attention to the bills they receive, so it doesn’t matter whether providers submit complete and timely bills and Second Reviews; or
• The claims administrators are incorrectly denying bills with the intent of creating even more friction to prevent providers from receiving payment for services rendered to injured workers.

Either way, providers end up sacrificing money, time, and resources when attempting to get paid.  It’s bad business, simply put, and every provider must take action and file an Audit Complaint when their bills are incorrectly denied.

&NOTE: The Audit Complaint form was updated in 2019. Access the updated form here: https://www.dir.ca.gov/dwc/Auditref.pdf

Learn how to easily file an Audit Complaint when a claims administrator incorrectly denies your bill:

• Read the How-to: Create Audit Complaint.
• Check out DaisyBill’s Audit Complaint Webinar to learn how to report claims administrators to the DWC. Watch the webinar video or download the slides--both are free!

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