Sedgwick Claims Management Services, daisyBill is here for you.

We notice that you struggle mightily with correctly calculating reimbursements under California’s Medical-Legal Fee Schedule (MLFS). Today’s post includes a particularly cringe-worthy example.

To assist you and to assist the entire community of California Medical-Legal evaluators, we’d like to make you an offer: you can use our daisyWizard Fee Schedule Calculator for FREE.

We’re serious.

Sedgwick, before you scoff at this gift, take a look at the story below. Everyone else, spoiler alert: it’s another payment train wreck brought on by California workers’ comp laws incentivizing claims administrators to adjust payments improperly.

Improper payment denials and adjustments are allowed to stand in California if the physician:

• Fails to submit a Second Review appeal within 90 days
• Fails to pay $180 to request Independent Bill Review (IBR) within 30 days of receiving the final Explanation of Review (EOR) in response to the Second Review appeal

Denying correct payment is a no-risk scenario; that’s why we call failure to properly reimburse a doctor a disingenuous game of “IBR Chicken.” Since California does not penalize the claims administrator for failing to reimburse the provider properly, the claims administrator always wins by default.

With a free daisyWizard subscription, Sedgwick has no excuse to pay incorrectly for Medical-Legal or any other services — unless they’re playing chicken.

Sedgwick Denies Med-Legal Bill for…Authorization?

Sedgwick initially denied payment to a Qualified Medical Evaluator (QME) for a Comprehensive Medical-Legal Evaluation, citing a lack of authorization.

The EOR is below. Cluck cluck.

As we’ve had to point out before, it makes no sense to claim a lack of liability or authorization for Medical-Legal services, as Medical-Legal services are rendered at the request of one or both parties.

Sedgwick Pays 50% MLFS on Second Review

To dispute the incorrect denial, daisyCollect timely submitted a Second Review appeal to Sedgwick on the QME’s behalf (remember, if no appeal is filed within 90 days, Sedgwick keeps the QME’s reimbursement).

On Second Review, Sedgwick suddenly realized they actually had to pay the bill. Unfortunately, how much reimbursement Sedgwick owed proved too tricky for the TPA to figure out; Sedgwick paid exactly half of the MLFS amount for the evaluation and record review.

The EOR is below (cluck. cluck. cluck.)

We get it: workers’ comp billing is complicated, even for TPAs.

That’s why daisyBill exists. And that’s why we’re offering Sedgwick the daisyWizard, a suite of tools that includes instant Fee Schedule Calculators. The Fee Schedule Calculator instantly determines a service's exact, accurate reimbursement amount.

For example, we plugged this situation into the ol’ Wizard, just to confirm the real MLFS rates as compared to the reimbursement sent by Sedgwick. This took literally seconds.

This is how easy we can make it for you, Sedgwick.

And bonus: the Wizard doesn’t just throw numbers at you. It also provides relevant details that went into the calculations, from the date of service to the location to fee-affecting regulations and NCCI edits.

In other words, we don’t just provide answers. We show our work, complete with the calculation formula — as in the Wizard screenshots below for one of the MLFS billing codes (and modifier) in question: ML201 (-95).

Sedgwick, this is a no-brainer.

The terms are simple: you get a powerful, easy-to-use tool that’ll make it incredibly difficult for you to miscalculate reimbursements. In return, we ask nothing more than your promise to use it (our attorneys insist on a pinky promise, as this is widely considered to be more legally binding).

Do we have a deal?

Know (and get) exactly what you’re owed for treating injured workers. Get instant, accurate fee schedule calculations with daisyWizard’s OMFS Calculator.

TRY THE CALCULATOR