Medical-Legal physician evaluators, be advised: a disturbing payment denial tactic is catching on among California claims administrators.

When responding to physician bills for Medical-Legal services that require a language interpreter, the claims administrator denies payment for Medical-Legal Fee Schedule (MLFS) billing code modifier -93. In the Explanation of Review (EOR), the claims administrator contends that the report does not adequately justify the use of an interpreter.

The latest offender: Cannon Cochran Management Services, Inc (CCMSI). Read on to learn how to defend practice revenue against improper modifier -93 denials.

CCMSI Denies Med-Legal Services as Non-Compensable

Recently a Qualified Medical Evaluator (QME) performed a Comprehensive Medical-Legal Evaluation with an interpreter. The evaluator reported MLFS billing code ML201 and modifiers -95 (for QME services) and -93 (for interpreter services).

CCMSI initially denied the bill on the grounds that the evaluation was non-compensable. Of course, as we’ve pointed out before, there can be no question of compensability for a Medical-Legal evaluation requested by the parties, even when the payer denies the compensability of the injury.

On the provider’s behalf, daisyCollect succeeded in getting CCMSI to pay for the evaluation by submitting a timely Second Review appeal (below) with the following language:

“Service incorrectly denied as non-compensable. Defense attorney issued a letter to the QME requesting a medical-legal evaluation. Provider documents service and time spent in report. Per CCR 9795(c), reimbursement is due for this medical-legal evaluation. Attached is an Overturn IBR Decision CB20-0000400 indicating this denial reason is incorrect. The attached letter serves as a formal written objection and notice of non-compliant EOR. An IBR will be filed upon failure to properly reimburse ML201-93-95.”

CCMSI Denies Modifier -93 on Second Review

Upon Second Review, Cannon Cochran dropped the bogus non-compensability argument. However, CCMSI reimbursed ML201, but denied the interpreter -93 modifier. 

CCMSI refused to remit the $201.50 increase represented by modifier -93 for interpreter services, claiming that “...information submitted does not support this level of service.”

Just like Berkley Net Underwriters, Cannon Cochran is seemingly leaning on the MLFS requirement that modifier -93 “requires a description of the circumstance and the increased time required for the examination as a result.” — as if the ‘circumstances’ that require an interpreter are not obvious.

In the previous article, we noted that “[f]or 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.”

As Cannon Cochran had already conducted Second Review, the only option to pursue full and correct reimbursement, including the increase for modifier -93, is to pay $180 to request IBR.

Below, daisyCollect’s IBR submission features the following appeal language for an improper modifier -93 denial:

Circumstances Requiring -93 modifier: The evaluator’s report documents the presence of an interpreter. The injured worker spoke a language different from the language spoken by the evaluator, therefore, 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.

To avoid improper modifier -93 denials, we strongly urge physician evaluators to include the language above — however silly it may seem — in:

• The report for any Medical-Legal evaluation requiring an interpreter, and
• Any Second Review appeal necessary to dispute denial of payment for modifier -93, and
• Any request for IBR necessary to dispute denial of payment for modifier -93

Apparently, certain claims administrators need help interpreting the purpose of interpreters.

Protect your practice. daisyBill helps providers get fast, accurate reimbursement for treating injured workers, at state fee schedule rates. Reach out to learn how we can help.

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