Providers continue to get squeezed between the twin incompetencies of Third-Party Administrator (TPA) Sedgwick Claims Management Services, Inc. and network payer Apricus.

As a TPA, Sedgwick is wholly responsible for providing compliant responses to providers’ bills for treating injured workers, even when a network payer like Apricus enters the equation by issuing reimbursements on Sedgwick’s behalf (generally after reducing those reimbursements under a network contract).

Yet again, a provider submitted compliant electronic bills (e-bills) to Sedgwick, only to receive no response well beyond the legal deadline. Yet again, Sedgwick denied payment after the provider resubmitted those unanswered e-bills. And yet again, Sedgwick responded to inquiries by passing the buck to Apricus, directing the provider to contact the network payer for answers.

daisyCollect contacted Apricus regarding the status of multiple bills, totaling nearly $40,000 in reimbursement due for care authorized by Sedgwick. Apricus responded that “cash posting delays” were holding up payments across its systems.

Ultimately, daisyCollect secured payment and obtained Explanations of Review (EORs) through an online portal. However, the provider has not received the “self-executing” penalties and interest due for untimely reimbursement or the legally mandated electronic Explanations of Review (e-EORs).

Yet again, this leaves Sedgwick in violation of state payment law and regulations. Sedgwick, of course, is no stranger to legal violations.

Sedgwick Passes Buck

As in the previous incidents, Sedgwick issued no response whatsoever for several original e-bills, which the provider sent back in February of this year.

California mandates that payers respond to all e-bills with an e-EOR within 15 working days, so payment details can automatically post to the provider’s e-billing system and the provider has the necessary documentation to dispute any denials or reductions in a timely manner.

In what has started to feel like a cruel joke, if a provider resubmits an e-bill Sedgwick initially ignored, the TPA does respond. The only problem is that, as in this case, Sedgwick’s response is to deny payment, citing that the e-bills are duplicate submissions.

When daisyCollect called Sedgwick to obtain information on why Sedgwick denied the e-bills as duplicates, since it had failed to respond to the original e-bills, the TPA reported that Apricus was responsible for the e-bills and provided an email address for further inquiry.

This is the administrative chaos providers must navigate to receive payment for treating injured workers: unanswered bills, laughable responses to valid resubmissions, and buck-passing to fourth-party entities.

Apricus Requests More Time

daisyBill emailed Apricus about the unpaid e-bills and received the response below, in which Apricus confirmed that no payment was issued due to “cash posting delays across our system” and asked us to “allow additional time.”

California’s Brutal Double Standard

To be clear: if a provider failed to submit an e-bill, Second Review appeal, or request for Independent Bill Review by the state-mandated deadline, there would be no “additional time.” Sedgwick would simply keep the reimbursement owed by default.

But because this is California, where laws and regulations seem to apply only to providers and go seemingly unenforced against payers, Apricus and Sedgwick can shrug off a $38,160 obligation without consequence. 

California requires payment of an e-bill within 15 working days, with penalties and interest due after 45 days; Sedgwick/Apricus took 81 working days to pay the oldest e-bill in this batch. However, the California Division of Workers’ Compensation (CA DWC) allows payers to “self-execute” penalties and interest payments for untimely reimbursement, rendering those payments effectively optional.

The CA DWC has also received formal Audit Complaints documenting hundreds of thousands of instances where Sedgwick failed to properly respond to a bill, to no effect whatsoever (and yes, daisyBill will submit more Audit Complaints reporting these latest violations, adding to the mountain we’ve already submitted).

Apricus’s glitch does not excuse Sedgwick from the law. But because of the twisted reality of the CA DWC’s approach to compliance, many laws that apply to payers seem to exist only in theory.

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