Few behaviors induce more cynicism than when claims administrators ask providers to withdraw requests for Independent Bill Review (IBR) in exchange for correct payment. Apparently, despite defending the incorrect bill reimbursement during both the original bill adjudication and the second review appeal, at the IBR stage, these claims administrators suddenly see the light and ask providers to stand down.
Whether the initial incorrect payment resulted from purposeful chicanery or seemingly strategic incompetence, the sudden epiphanies of claims administrators like California’s SCIF (State Compensation Insurance Fund) should cause outrage throughout the workers’ comp community.
When providers submit an original bill and second review appeal, SCIF is confident in its incorrect reimbursements. Subsequently, when providers request IBR, SCIF suddenly sees the error of its ways and asks providers to withdraw these IBRs.
If a provider refuses to withdraw an IBR request, SCIF throws what can generously be described as a tantrum.
The Painful and Expensive Appeals Gauntlet
If a claims administrator fails to remit the correct reimbursement for authorized services, the provider must undergo a grueling gauntlet to secure the compensation allowed by the fee schedule, including a second review appeal process, followed by the IBR process.
Providers request IBR from Maximus, California’s designated independent bill reviewer. Doing so requires the provider to pay a filing fee of $195, refundable by the claims administrator if Maximus rules in the provider’s favor. However, Labor Code 9792.5.11 allows the provider to withdraw the request at any time before Maximus issues their Final Determination.
We strongly recommend that providers NEVER NEVER withdraw an IBR request at the behest of the claims administrator. Not only does IBR statistically favor the provider, but too many providers have learned the hard way that trusting the claims administrator to pay...well, just doesn’t pay.
Promises, as it turns out, do very little for providers by way of revenue management.
SCIF: Cynicism Defined
In a recent case, SCIF asked the provider in question to withdraw its IBR, making the usual promises of full and timely payment. The provider refused, trusting in the strength of his case rather than putting his faith in the claims administrator.
In response, SCIF threw a tantrum and submitted a new, 53-page dispute packet to Maximus claiming the provider failed to submit the applicable PPO contract with the IBR application. The PPO contract was not disputed; therefore, not applicable.
You read that right. First, SCIF admits its “error” then, after unsuccessfully asking the provider to withdraw the request in exchange for full payment, SCIF submits 53 pages refuting the IBR request. This is the very definition of cynical as being “concerned only with one’s own interests and typically disregarding accepted standards in order to achieve them.
In the latest example, it seems SCIF borrowed a page from the Zenith playbook of contradictory IBR objections.
Workers’ Comp Subverted
Clearly, SCIF was admittedly in the wrong by failing to properly reimburse the provider.
Rather than demonstrating the appropriate compunction over its payment “error,” SCIF attempted to undermine the provider’s IBR appeal by submitting a baseless and pointlessly lengthy objection to derail the process — or at least slow it down.
This objection by SCIF did no more than belie the cynicism behind SCIF’s approach to properly reimbursing providers that treat injured workers.
Maximus overturned SCIF’s incorrect reimbursement, ordering SCIF to pay the bill in full along with the $195 filing fee. We hope SCIF is timely and compliant with Maximus’ findings, unlike some claims administrators in the recent past. And we hope providers take the key lesson from this story: never capitulate during the IBR process.
The sustained pattern of delayed and/or incomplete payment, miraculously reversing once a provider pays $195 to submit an IBR to appeal, hurts workers’ comp by forcing providers to expend precious resources to simply receive the reimbursement due per the state fee schedule.