Sedgwick Denies Second Review Appeals as "Duplicates"

Sedgwick Denies Second Review Appeals as "Duplicates"

Sedgwick has a Second Review problem.

On too many occasions, Sedgwick incorrectly denies providers’ Second Review appeals as “duplicate submissions” of the original bill. As a result, providers must request Independent Bill Review (IBR), at a further cost of time, resources, and the $180 IBR filing fee (refundable only if the provider prevails at IBR).

It is impossible for us not to ask: is Sedgwick being inept, cynical, or some combination of the two when denying a compliant appeal as a duplicate bill?

There is no good answer.

Sedgwick’s Second Review Pattern: Method or Madness?

We’re seeing a pattern here. According to data from our concierge billing service, DaisyCollect, Sedgwick routinely denies providers’ Second Review appeals as duplicate bills.

Rather than addressing the clear and detailed dispute reasoning provided on the Second Review form, Sedgwick absurdly treats the appeal as an improper resubmission of the original. This is patently ridiculous, as the Second Review appeals are unmistakably just that — Second Review appeals, not original bills.

DaisyBill clients submit Second Review appeals electronically using the DWC SBR-1 form. In other words, Sedgwick receives these appeals on a distinct, standardized document universally recognized as a Second Review appeal, as displayed in the example below:

In addition, per the guidelines found in both the DWC’s Medical Billing and Payment Guide and California Code of Regulations (CCR) Section 9792.5.5., DaisyBill also electronically submits a properly modified CMS-1500 original billing form. To indicate an appeal, Box 10d of the CMS-1500 is populated with “BGW3.”

For good measure, we also populate box 19 for “Additional Claim Information” with “RECONSIDERATION!” as displayed below:

Yes, we use all caps and an exclamation point to clearly distinguish the appeal from the original bill.

DaisyBill Second Review appeals are 100% compliant and foolproof — but apparently not Sedgwick-poof.

Somehow, against all odds (and standards of basic competence), Sedgwick manages to mistake a standardized appeal form and an unmistakably labeled CMS-1500 for an original bill, time and time again.

In the Final Explanation of Review (EOR) below, Sedgwick denies the above documents as a duplicate of the original bill, rather than an appeal for reconsideration:

Again, this is not an isolated incident. The table below lists IBR cases in which Sedgwick misadjudicated Second Review appeals in exactly the way shown above:

Employer

CPT Codes Disputed

Amount Disputed

Dispute Reason

IBR Decision

Cardenas Markets, LLC

ML106-95

$375.00

Fee Schedule Error: Med-Legal Supplemental After 4/1/2021 Denied

Pending

McCarthy Building Companies Inc

ML102-93-95

$687.50

Claim Non-Compensable: Med-Legal

Pending

Kaiser Permanente San Leandro Medical Center

ML103-95

$937.50

Documentation Insufficient: Med-Legal

Pending

County of Napa

90834-59-95

$144.60

Coding Error: Not Separately Payable

Pending

Sullivan Thompson Masonry and Restoration

ML106

$875.00

Fee Schedule Error: Med-Legal Supplemental After 4/1/2021 Denied

Pending

City of Alameda

90834-95-59

$135.86

Coding Error: Not Separately Payable

Overturn

City of Alameda

90834-95-59

$135.86

Coding Error: Not Separately Payable

Overturn

County of Napa

90834-95-59

$131.30

Coding Error: Not Separately Payable

Overturn

NEA Delivery, LLC

ML101-95

$1,000.00

Documentation Insufficient: Med-Legal

Overturn

City of Newark

90834-95-59, 90901-95

$190.65

Coding Error: Not Separately Payable

Overturn

Cardenas Markets, LLC

ML106-95

$750.00

Documentation Insufficient: Med-Legal

Overturn

CBC Steel Buildings, LLC

ML106-95

$500.00

Fee Schedule Error: Incorrect Units Reimbursed

Overturn

Macy's West Store Inc

ML106-95

$750.00

Documentation Insufficient: Med-Legal

Overturn

CBC Steel Buildings, LLC

ML102-95

$625.00

Claim Non-Compensable: Med-Legal

Overturn

Sensient Technologies Corporation

ML106-95

$500.00

Documentation Insufficient: Med-Legal

Overturn

Macy's

ML102-95

$625.00

Claim Non-Compensable: Med-Legal

Overturn

Freeman Exposition Inc

ML106-95

$12,312.50

Documentation Insufficient: Med-Legal

Overturn

Amazon

ML101-95

$1,750.00

Documentation Insufficient: Med-Legal

Overturn

Genesis Healthcare Warranty, LLC

99205, 99354, 96130-59, 96131

$818.77

Authorization: No Authorization

Overturn

Laurel Landscapes, Inc.

ML106

$500.00

Documentation Insufficient: Med-Legal

Overturn

Pepsi Beverages Company

ML103-95

$312.50

Coding Error: Med-Legal Downcoded

Overturn

Bright Hism LLC

ML106-95

$500.00

Adjustment Reason Code Insufficient

Overturn

FedEx Ground Package System, Inc.

ML106-94

$2,968.75

Claim Non-Compensable: Med-Legal

Overturn

St. Joseph Hospital

96139, 96138-59, 96131, 96130-59, 99354, 99205, 90901

$331.19

Fee Schedule Error: Old Fee Schedule Used

Overturn

Apple

90901, 90834-59, WC002

$21.02

Fee Schedule Error: Old Fee Schedule Used

Overturn

Food Co (Food 4 Less)

90901, 90834-59, WC002

$10.85

Fee Schedule Error: Old Fee Schedule Used

Overturn

Sedgwick suffers no consequences for torturing providers with these “duplicate” denials. These Sedgwick denials force the provider to expend enormous efforts to receive correct payment, and we suspect Sedgwick knows this.

With that, we can only appeal to Sedgwick: please learn the difference between an original bill and a Second Review appeal, or stop processing appeals as if you don’t know the difference. Every one of these absurd denials means more wasted provider time and resources, and more friction in an already inefficient system.


We make Second Review appeals easy. With just a few clicks, you can make sure that when claims administrators miss the mark, they correct their mistake. Contact us to learn more.

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