California’s all-new Medical-Legal Fee Schedule (MLFS) debuted back in April, but some claims administrators are still a few steps behind.

To bill for supplemental Medical-Legal reports, the Division of Workers’ Compensation (DWC) instructs that the date of the request for the report — not the date of service — is the sole factor in determining whether to apply ML203, or the previous billing code ML106:

• ML203 is used when the supplemental report is requested on or after April 1, 2021 and
• ML106 is for supplemental reports requested before April 1, 2021

Yet, Liberty Mutual ignored the new MLFS regulations and incorrectly denied payment for ML106 based on the date of service. This denial forced the provider to pay $180 and request Independent Bill Review (IBR), simply to receive payment for a Medical-Legal service requested by an attorney representing Liberty Mutual.

Unfortunately, when payers fail to keep up with the law, the provider must shoulder the load of pursuing payment justice.

ML106 vs ML203

Liberty Mutual provides a classic example of a claims administrator’s failure to keep up with changing regulations. California Code of Regulations Section 9795(f) includes instructions on when to apply the new MLFS billing codes:

(f) This section shall be effective as of April 1, 2021 and shall apply to the following: (1) Medical-Legal evaluation reports where the examination occurs on or after April 1, 2021; (2) Medical-Legal testimony provided on or after April 1, 2021; and (3) supplemental medical legal reports that are requested on or after April 1, 2021 regardless of the date of the original examination. [Emphasis added]

As the letter below demonstrates, the Law Office of Monika Hight represents Liberty Mutual regarding the claim in question, and acknowledged the provider as the Agreed Medical Evaluator (AME) responsible for providing Medical-Legal services:

Hight’s office, on behalf of Liberty Mutual, requested a Supplemental Medical-Legal Evaluation report on February 15, 2021. This is well before April 1, 2021, the date after which ML203 would be the appropriate code to bill for the report.

For anyone familiar with the regulations, one glance at a calendar confirms that the provider was correct in billing ML106, regardless of when the provider furnished the requested supplemental report.

Accordingly, the provider submitted a timely bill for the supplemental report, correctly billing ML 106.

Liberty Mutual’s Failure = Provider’s Torture

As you may have guessed, Liberty Mutual incorrectly denied payment for the supplemental report, based on the date of service. This forced the provider to expend time, effort, and resources in an Odyssian struggle to correct Liberty Mutual’s error.

First, Liberty Mutual denied the original bill, incorrectly claiming the provider used an inappropriate HCPCS/CPT code:

The provider (appropriately) submitted a Second Review appeal, giving Liberty Mutual a chance to correct its error. Liberty Mutual denied payment, again. This forced the provider to request IBR, again at a cost of $180 (refundable only if the provider wins the case).

When the state’s designated IBR entity, Maximus, gave Liberty Mutual an official opportunity to dispute the case’s eligibility for IBR, Liberty Mutual tripled down on its erroneous interpretation of Medical-Legal billing rules, claiming:

“As of 04/01/2021, there are new med legal billing codes the provider should be billing with.”

Now the provider can only wait for the IBR decision, and hope to recover both the correct payment and the $180 IBR filing fee.

The Burden of Proof in Workers’ Comp

Liberty Mutual requested a Supplemental Medical-Legal evaluation. Liberty Mutual incorrectly adjudicated the provider’s bill for the evaluation, twice. Liberty Mutual incorrectly asserted that the provider “should be billing with” the new Med-Legal Codes.

And yet, it’s the provider who suffers the consequences of Liberty Mutual’s failure to adhere to the new MLFS. 

Again, all of this stems from a report requested by Liberty Mutual, via their attorney. There are ZERO consequences for Liberty Mutual for their errors. Instead, to pursue correct reimbursement, this provider submitted dozens of pages of required documentation, as follows.

Even if the state’s designated IBR entity, Maximus, makes the correct IBR decision, the larger problem remains: in workers’ comp, the burden of correcting payer failures always falls on the provider.

The overwhelming advantage afforded to payers in such disputes is unconscionable.

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