SCIF Makes Mockery of IBR and the DWC

SCIF Makes Mockery of IBR and the DWC

Yet again, we face another appalling round of "IBR Chicken,” the game in which a claims administrator refuses to shell out a dime to a California provider for services rendered — until the provider spends $180 to request Independent Bill Review (IBR).

And why not? After all, IBR Chicken is a game the claims administrator can always win.

In IBR Chicken, the worst case scenario for the claims administrator is being ordered to pay the amount owed, and maybe the IBR filing fee…and certainly no interest or penalties.

The best — and far too often, the likeliest — scenario is the claims administrator fattens its bank account by keeping the reimbursement owed, if the provider fails to undertake even one step of the arduous appeals process.

In the dispute below, the State Compensation Insurance Fund (SCIF) ultimately admitted owing full reimbursement to a Qualified Medical Evaluator (QME), after an eight-month charade of false payment denial reasons. Brazenly, SCIF defended its false denials with demonstrably untrue assertions to the Division of Workers' Compensation (DWC).

When will California, the DWC, and the state’s IBR proxy, Maximus, see this fowl game for what it is?

Most importantly, when will the state do something to discourage the kind of provider abuse that SCIF inflicts with audacity — and without a shred of consequences?

SCIF - ‘S’ Is for Shameless Payment Denial

On September 12th, 2022, the QME reviewed 58 pages of records and wrote a Supplemental Medical-Legal Evaluation report at the request of the Applicant's Attorney. On September 14th, the QME billed SCIF — and included with the bill submission all of the following documents:

  • The Supplemental Medical-Legal Evaluation report
  • The Initial Comprehensive Medical-Legal Evaluation report (for which SCIF had paid the QME) 
  • The attorney request letter for the Supplemental Report
  • The required record review page count attestation

Yet on September 22nd, SCIF denied payment for the Supplemental report, citing the claim is “non-compensable” and the carrier (SCIF) is “not liable.”

Let’s say this for roughly the zillionth time: Medical-Legal services exist to determine liability/compensability at the parties' request. Not to mention, SCIF had paid for the Initial Comprehensive Medical-Legal report.

With this shameless denial, SCIF kicked off “IBR Chicken.”

The rules are simple: deny payment, wait for an appeal, and deny the appeal. If the provider manages to pay $180 to file for IBR, pay the amount initially billed, then ask for the IBR request to be denied.

SCIF - ‘C’ Is for Clucking Audacity

Remember: if a provider fails to submit a Second Review appeal to dispute a false denial within 90 days of receipt of the Explanation of Review (EOR), the claims administrator keeps the provider’s reimbursement.

On September 29th, daisyCollect submitted, on the QME’s behalf, a Second Review appeal to SCIF disputing the absurd denial. The appeal included all of the following:

  • California Code of Regulations Section 9795(c), which mandates payment of ML203
  • An example IBR decision (CB22-0000143) overturning a ML203 payment denial that listed a similar denial reasoning used by SCIF
  • A formal objection letter, with a statement of intent to pursue IBR if necessary
  • SCIF’s EOR
  • The Supplemental Medical-Legal Evaluation report
  • The Initial Comprehensive Medical-Legal Evaluation report (for which SCIF reimbursed the QME)
  • The attorney request letter for the Supplemental Report
  • The required record review page count attestation

daisyCollect couldn’t have made it easier for SCIF to realize its…error. Unfortunately, as they say, you can lead a horse to water — but the chickens won’t give a cluck.

On October 12th, SCIF denied the Second Review appeal, repeating the false, inapplicable “carrier not liable” denial reason.

SCIF - ‘I’ Is for Insidious

On October 26th, daisyCollect paid $180 to Maximus to submit a request for IBR to dispute SCIF’s denial. The IBR request included all of the documents the provider sent to SCIF — twice.

Then…nothing happened for six months.

On April 19, 2023 Maximus sent SCIF the formal Opportunity for the Claims Administrator to Dispute Eligibility. On May 4, 2023, SCIF responded to Maximus with a 181-page objection (you read that right), claiming Maixumus should deem the dispute ineligible for IBR because…wait for it…

The provider has violated Title 8, CCR Section 9792.5.7(b)...The provider is disputing the applicability of the contractual agreement and not the amount of payment owed.”

As if that wasn’t enough already, SCIF added:

“Additionally, the payment dispute involves a billed amount that has been reimbursed per the fee schedule.”

What the cluck?!

You may ask: What contractual agreement? Isn’t this a Med-Legal bill? Obviously there is no “contractual agreement” at issue — just a claims administrator that’s either too inept to understand that, or too audacious to tell a more plausible lie.

Further, SCIF falsely asserted that the provider “has been reimbursed.” For the record, and for the love of all things decent in this world, SCIF had not reimbursed the provider a single dime as of May 4.

Below is the first page of the SCIF novel, erm, letter in which SCIF falsely accuses the QME of violating California regulations and claims to have already paid.

SCIF - ‘F’ Is for Fox

On page 3 of SCIF’s manifesto, the insurer admits in writing:

“After careful review of the Request for Independent Bill Review, the supporting documentation and discussion with the claims adjuster, it has been determined that payment is due.”

The audacity of SCIF admitting that it only undertook a “careful review” after the provider filed for IBR is staggering.  Twice the provider sent SCIF the exact documents the provider sent to Maximus in the IBR. Twice SCIF denied payment for ML203 using a preposterous denial reason.

On page 3, SCIF further admits that a $674.00 “Payment is in the process of being issued.” This despite falsely asserting (on page 1) that SCIF had paid the QME.

Predictably, SCIF’s “payment” fails to include:

  • Interest
  • Penalties
  • The $180 IBR filing fee

Not to mention reimbursement for the time, frustration, and administrative resources that went into this wild chicken chase.

California, this isn’t  a “no harm, no fowl” situation. This sordid story exposes SCIF for the fox it is, making the most of a payer-friendly appeals process to raid the henhouse of California workers’ comp.

Providers rely on the DWC and Maximus to enforce the rules. But there comes a time when the state must open its eyes to the reality that claims administrators like SCIF are playing a different, far more insidious game — one of blood and feathers.

Med-Legal billing requires specialized expertise. daisyCollect professionals use our advanced software (and years of experience) to protect your practice. Request a demo below:


0 Reader Comments
There are no comments for this article. Be the first to comment!
How did you like the article ?

DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.