Sedgwick Claims Management Services, Inc., a Third-Party Administrator (TPA) of workers’ comp claims, has set a horrifying new standard for how claims administrators can ignore California law without consequence.

California providers must submit Second Review appeals to claims administrators to dispute incorrect denials or reductions of payment for workers’ comp services. If a provider fails to submit a timely Second Review appeal, they forfeit any reimbursement owed.

But rather than responding compliantly to providers’ appeals (as required by law), Sedgwick has made a glaring habit of incorrectly denying valid, compliant Second Review appeals as alleged “duplicates” of the original bills in question—at rates that strain even the most elastic credulity.

Verifiable data show that in 2024, 67% of the Second Review appeals denied by Sedgwick were denied as “duplicates.” In September, Sedgwick incorrectly claimed a “duplicate bill” for 89% of denied appeals.

Below, we present almost six years of Second Review data demonstrating Sedgwick’s habit (or business practice?) of refusing to respond compliantly to providers’ appeals for correct reimbursement.

The state's Division of Workers ' Compensation (CA DWC) is complicit in this abuse, which affects thousands of California providers. In its refusal to enforce the laws and regulations it’s meant to uphold, the CA DWC has created a workers’ comp system that allows Sedgwick to financially maul providers year after year with impunity.

Sedgwick: 22,155 Free Passes From CA DWC

The CA DWC has been aware of Sedgwick’s Second Review non-compliance since at least June 2022, when daisyBill submitted a formal Audit Complaint detailing 4,930 instances.

In June 2024, daisyBill filed a second Audit Complaint for 17,225 improper denials. In total, daisyBill has presented the DWC with credible data detailing 22,155 instances of Sedgwick’s failure to adhere to California laws and regulations regarding Second Review appeals.

daisyNews is not the only outlet that has noticed Sedgwick's audacity in misidentifying Second Review appeals as “duplicate” bills.

Even the blog of defense (i.e., claims administrator) attorneys at Friedman + Bartoumian condemns the “disturbing” rates at which some claims administrators’ bill reviewers “act as if they have never seen Form SBR-1,” the form used for Second Review appeals since 2014—and which daisyBill uses for every Second Review appeal sent through our system.

The defense attorneys’ blog post raises further questions regarding the motives behind this non-compliant behavior (emphasis ours):

“DWC records reveal that an astounding 22,155 audit complaints are currently on file against just one bill review company for inappropriately raising “duplicate submission” as an excuse for denying reconsideration. Physicians can’t help but wonder if bill reviewers are doing this on purpose.”

While Friedman + Bartoumian does not identify any particular bill review services or claims administrators, the reference to the 22,155 Audit Complaints leaves little doubt about the culprit: Sedgwick.

Sedgwick’s “Duplicate” Problem

The table below shows the rates at which Sedgwick incorrectly denied Second Review appeals submitted through daisyBill as “duplicate” bills from January 2019 to October 2024.

Note that from August 2019 to August 2020, the monthly improper denial rates dropped precipitously, statistically to as low as 0%. This indicates that Sedgwick can eliminate this nonsense. So why did Sedgwick do otherwise, both before and after this drop?  

From August 2020 on, despite repeated outreach and multiple formal complaints to the state, Sedgwick's disregard of California laws and regulations has gotten progressively worse. In September 2024, 89% of the Second Review appeals Sedgwick denied were misidentified as “duplicates.”

That number should provoke an example-setting response from the state, but will likely be met with the CA DWC’s characteristic inaction. These data beg the question: what, if anything, has the DWC done to curb Sedgwick’s brazen behavior or protect providers? The answer seems to be: nothing.

While the CA DWC seems content on the sidelines, workers’ comp doctors go unpaid and underpaid—until those doctors simply stop appealing or stop participating in this hopelessly mismanaged system.

Data: Sedgwick Improper Second Review Appeal Denials 2019-2024

The CA DWC (and readers of daisyNews) are well aware of Sedgwick’s behavior, demonstrated in the data below, which harms providers. Unfortunately for injured workers, the CA DWC and its Administrative Director’s only response is silence.

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