Today we’re sharing a maddening and all-too-common story of payment woes, this time featuring Liberty Mutual as the miscreant that just won’t pay a bill correctly -- despite being in the wrong, despite being ordered to do so, despite SIX voicemails and over two hours on hold by our intrepid DaisyBill Compliance Team, and despite the passage of several seasons.

California’s current work comp regulations place the entire burden on providers to timely appeal incorrect payments. When a claims administrator refuses to pay the correct amount, the provider must timely submit a Second Review appeal, followed by an Independent Bill Review (IBR). The IBR entails sending complex paperwork to Maximus and paying a $195 filing fee, as well as sending a copy of the IBR to the claims administrator. If a provider fails to timely or compliantly submit these appeals for correct payment, the provider’s bill is dismissed by the claims administrator with no additional funds due to the provider.

It didn’t take long for claims administrators to deduce that, without dedicated technology like DaisyBill’s, it was practically impossible for providers to scale this prohibitive appeal mountain, especially for small amounts that were incorrectly reimbursed. Thus, claims administrators regularly deny providers Second Review appeals for correct payment, because there are truly zero reasons to correctly pay the provider. No penalties, no interest due, no audits, no consequences.

What follows is but one example among many that show how the lack of consequences for claims administrators unravels the workers’ comp payment process, a cautionary tale not only for the improperly paid provider but also for employers and government entities.

• While this specific tale redacts the employer’s name, all employers that use Liberty Mutual as a claims administrator need to carefully read this perversion of workers’ comp claims management, including Costco, JP Morgan, Home Depot, UPS, Comcast, etc.
• All providers treating injured workers need to read the tortuous details of Liberty Mutual’s persistent, unwarranted, and just plain wrong denials. Consider this provider a proxy for all providers who want to receive correct reimbursement for treating injured employees.
• All California government officials and regulators need to know that this provider consistently submits IBRs for incorrect payments and that Liberty Mutual threatened to kick this provider out of its Medical Provider Network.

1. The tale commences on 2/27/2019 with Liberty Mutual incorrectly reimbursing two CPT codes and the provider committing a billing error by neglecting to add an appropriate modifier to one code.

Liberty Mutual Bill Review correctly denies the code missing the modifier, but there is no excuse for the two incorrect reimbursements which total $10.99. Liberty Mutual should be held responsible for correctly reimbursing providers per the California Official Medical Fee Schedule (OMFS).

*Note to employers, providers, and regulators: Without accountability, this reimbursement tale demonstrates the Kafka-esque trials inflicted on a provider trying to collect the correct reimbursement that the state deems is appropriate for treating California injured employees.

2. The next day, on 2/28/2019, the provider submits a timely Second Review appeal to Liberty Mutual requesting the correct reimbursement of $10.99 for the two CPT codes incorrectly reimbursed.

Further, in the Second Review appeal, the provider explains the billing error and amends the 96130 billing code by adding the correct modifier. With the correction, an additional $166.99 is due for this CPT code.

3. On 3/8/2019 Liberty Mutual denies the Second Review appeal and refuses to correctly reimburse the provider both the $10.99 and $166.99.

*Note to employers, regulators, and providers: the California Official Medical Fee Schedule clearly denotes the reimbursement due to the provider. By failing to correctly reimburse this provider, Liberty Mutual undermines California workers’ comp by placing the burden on the provider to pay $195 to file an Independent Bill Review to obtain the correct $177.98 reimbursement.

4. To collect the $177.98 correct reimbursement due per the OMFS, on 3/14/2019 the provider pays the $195 IBR fee and submits a 46-page IBR document to Maximus.

5. On 5/31/2019 Maximus rules in favor of the provider and determines Liberty Mutual owes the provider the correct reimbursement of $177.98 and the $195.00 IBR fee.

6. On 7/12/2019 Liberty Mutual reimburses the provider the $195 IBR filing fee. Liberty Mutual does not pay the $177.98.

7. 8. 9. 10. 11. 12. 13. To obtain the additional $177.98 reimbursement awarded by Maximus, our team left a total of SIX voicemails with Liberty Mutual. After the fourth voicemail, the DaisyBill Compliance Team received a response from Liberty Mutual with instructions to contact Liberty Mutual Bill Review. As instructed (and as we wrote about previously), we contacted Bill Review and we were placed on hold for two hours, ten minutes.

14. On 9/19/2019 Liberty Mutual finally issues the provider a check for $177.98. The payment finally materialized but only after:

• 111 days from the Maximus decision, instead of the required 45 days
• 203 days from the date the provider submitted the Second Review appeal requesting correct payment

Is this the way that providers should be treated? Is this how we want doctors rewarded for tending to injured employees? And is this any way for a claims administrator to act on behalf of its employer clients?

Stay on top of the latest news in the world of workers’ comp billing and payment — including claims administrator (mis)behavior, rule changes, and other news that can affect your practice. Click below to subscribe to our blog:

STAY ON TOP OF WORKERS’ COMP