Third-Party Administrator (TPA) Intercare underpaid a California provider for an injured worker’s treatment. After daisyCollect submitted a Second Review appeal on the provider’s behalf, Intercare sent additional reimbursement, but it was still not the correct amount. Accordingly, daisyCollect requested Independent Bill Review (IBR) to recover the full amount Intercare owed.

Then, things got weird.

In response to the IBR request, AvonRisk, Intercare’s parent company, demanded a W-9 form from the provider in order to “process payment”...despite having already issued payments for this bill twice before.

daisyCollect acquiesced and sent a W-9 to AvonRisk. In response, AvonRisk claimed the W-9 was insufficient because it listed the billing provider (i.e., the practice name) rather than the specific rendering provider as listed on the IBR request.

With the utmost patience, daisyCollect explained to AvonRisk that:

• The billing provider name listed in Box 33 of the original CMS-1500 billing form and on the W-9 on file with AvonRisk/Intercare determines payment (regardless of the specific rendering provider listed on the IBR request).
• Intercare has already processed and issued payments for the bill in question twice. There is no question as to whom Intercare is supposed to pay.

AvonRisk and Intercare’s oddball demands have no basis in California law or regulations. Does Intercare intend to “process payment” correctly before the state can conduct IBR (a classic gambit in the game of “IBR Chicken”)? If so, why does Intercare suddenly need a new W-9 after already issuing two payments on this bill?

This is exactly the kind of pointless, time and resource-consuming administrative horseplay that results from an excess of private equity-backed intermediaries adding layers of profitable friction to every claim.

The employer, Reiter Affiliated Companies, engaged an insurer, which in turn engaged AvonRisk/Intercare and its gaggle of middleperson vendors, including Third-Party Administrator (TPA) Intercare. AvonRisk is owned by Aquiline Capital Partners, the ultimate beneficiaries of this dysfunction.

Intercare Underpays, AvonRisk Overcomplicates

After Intercare underpaid the provider for both the original bill and the subsequent Second Review appeal, IBR was the only recourse. Accordingly, daisyCollect filed a compliant IBR request with Maximus (the state's independent reviewer), and, concurrently, sent a copy of the IBR request to Intercare.

We’ve seen a wide variety of payer reactions to IBR requests before, including sudden reversals of payment denials and reductions, followed by demands that the provider withdraw the request. But this was the first time we’ve seen a payer’s corporate overlord step in and muddle the process with a demand that, frankly, made no sense.

AvonRisk sent the message below to daisyCollect, asking for a W-9 (which, presumably, Intercare already has, given that it paid the original bill and Second Review appeal).

daisyCollect furnished the W-9 as requested, which listed the billing provider (i.e., the name of the practice). AvonRisk responded by claiming that the W-9 was unacceptable because the IBR request listed the specific rendering provider by name rather than the practice name.

An AvonRisk representative stated:

“To process this payment, we need w9 per info on [IBR] document. If you need the payment pay [sic] to [Billing Provider/Practice Name] then please resubmit the bill with correct name and address to Bill Review Dept.”

The message included an image of a portion of the DWC IBR-1 Form from the IBR request (below), with the provider name circled:

In response, daisyCollect pointed out that the provider name as listed on the original bill is the only information necessary to know where to send payment, regardless of whether the IBR request lists the individual rendering provider.

Moreover, Intercare had no issue “processing payment” without a new W-9 for the original bill and Second Review appeal. If IBR determines that Intercare owes more, all they need to do is send more money to the practice to which they already sent two previous payments.

None of this back-and-forth is necessary to resolve the billing dispute at hand; the provider’s bill, appeal, and IBR request were compliant to a tee. Maximus, the state’s independent reviewer, will make its determination regardless of AvonRisk’s wholly manufactured W-9 issues.

The only question is whether AvonRisk/Intercare will attempt to pay correctly prior to Maximus proceeding with the dispute, IBR Chicken-style, or use the W-9 (non) issue as a pretext for failing to remit full payment after Maximus rules.

Either way, it’s a typical example of time and resources wasted in pursuit of private equity returns on investment, as generated by administrative friction that arguably serves no truly useful purpose for injured workers or the providers who treat them.

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