According to Third-Party Administrator (TPA) Sedgwick, the County of Orange refuses to reimburse providers for treating injured employees via telehealth.

Sedgwick claimed that all of Orange County’s Medical Provider Network (MPN) members were somehow notified of the no-telehealth stipulation. But when pressed for proof of said notification, Sedgwick provided none.

Sedgwick also acknowledges that the policy is not disclosed in documents authorizing treatment.

Below, see the emails between a practice and a Sedgwick “Return to Work” specialist. As you read, try not to lose all hope as an employer and its TPA trample established treatment regulations in favor of whatever suits their whims.

All providers treating Orange County employees should note that Orange County and Sedgwick may attempt to deny payment for authorized treatment when provided via telehealth. 

The provider pushed back in this case, clarifying that the practice would cease treating Orange County employees over its no-telehealth policy. Sedgwick ultimately paid the bill. Without meaningful enforcement from the state, providers must take a cue from this practice and its refusal to accept this kind of payment abuse.

It is past time providers made a habit of exercising their power to insist on proper treatment for injured employees and proper compensation for that treatment. Collectively, providers can improve workers' compensation.

Sedgwick: County of Orange Refuses to Pay

In the email below, a Sedgwick representative told a provider that the TPA “cannot guarantee payment” for services rendered via telehealth because “the County of Orange (COO) refuses to pay for virtual and telehealth appointments.”

The Sedgwick representative asserted that the provider was notified of this no-telehealth policy. Still, the Sedgwick representative failed to furnish any proof that Orange County informed providers that all its injured employees are “to be seen in person for all appointments.”

The practice responded with appropriate incredulity and clarified that random payment policies dictated outside the Official Medical Fee Schedule (OMFS) are unacceptable — and would force the practice to cease treating Orange County employees.

As the practice correctly pointed out in a post-COVID, Internet-enabled world, “Virtual is a reality the County of Orange needs to get on board with.”

We commend this practice for taking a stand. By refusing to accept non-compliance, providers can force claims administrators to follow the workers’ comp laws and regulations woefully under-enforced in California.

Provider Requests Proof of Notification of “No Telehealth” Policy

In the emails below, practice staff questioned whether the practice had been informed of the strange policy before rendering treatment.

In response, the Sedgwick representative could only report “believing” that providers in Orange County’s MPN were notified sometime in the preceding 18 months that the policy was “expected to be adhered to.” Sedgwick offered no proof of such notification.

However, the Sedgwick representative concedes that authorizations sent for treatment do not mention the no-telehealth policy, stating, “We do not include this verbiage on any auth forms.”

Not satisfied with the Sedgwick representative’s “belief,” the practice had a reasonable request: show us proof that Orange County notified us that telehealth was a no-go.

Moreover, the practice reminded Sedgwick that it is the provider’s choice to treat — or not treat — Orange County employees.

Sedgwick could provide no proof. Following further email exchanges (to be explored in upcoming articles), Sedgwick paid for the telehealth services.

Providers treating Orange County employees, be advised. This employer and its TPA have concocted self-serving payment rules, with no evidence that providers are even informed of these rules. If you treat Orange County employees via telehealth, be prepared to fight for reimbursement.  

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