You can’t say we didn’t try.

Earlier this month, we offered Third-Party Administrator (TPA) Sedgwick Claims Management Services, Inc. 100% free use of our daisyWizard fee schedule calculator. That followed Sedgwick’s nonsensical denial of a bill for Medical-Legal services, followed by incorrect payment at 50% of Medical-Legal Fee Schedule (MLFS) rates.

We thought it was a no-brainer. Rather than continuing to display what appears to be abject ineptitude in the ol’ bill review department, Sedgwick could get instant, accurate reimbursement calculations in seconds.

But we never heard back. Now Maximus, the Independent Bill Review (IBR) organization tasked with resolving reimbursement disputes on behalf of the Division of Workers’ Compensation (DWC), has ordered Sedgwick to pay up, in full.

Offer’s still on the table, Sedg. We’re here for you.

Sedgwick Fails MLFS Math

Sedgwick first denied payment to a California Qualified Medical Evaluator (QME) on extremely silly grounds: lack of authorization.

As we know (and as anyone whose entire job is to administer workers’ comp claims should know), Medical-Legal services are requested by the parties; authorization is a non-issue.

After daisyCollect timely filed a Second Review appeal, Sedgwick finally paid — half of what was owed.

That’s when we thought we’d take one for the team (“the team” being all workers’ comp stakeholders subject to Sedgwick claims administration) and give Sedgwick what it clearly, desperately needs: a tool for calculating fee schedule reimbursements.

Maximus Drops the Gavel

With no other choice, daisyCollect paid $180 to request IBR — something we’re forced to do often, as many claims administrators seemingly can’t resist a good ol’ game of IBR Chicken.

For those unfamiliar with IBR Chicken, it looks as follows:

1. The claims administrator incorrectly denies or adjusts payment.
2. If the provider fails to request Second Review within 90 days, ka-ching! The claims administrator keeps the reimbursement owed.
3. If the provider requests Second Review, the claims administrator denies again (or if they’re feeling generous, pays a little).
4. If the provider fails to request IBR within 30 days, ka-ching! The claims administrator keeps the reimbursement owed.

In this case, Maximus agreed Sedgwick owed the QME the additional reimbursement. But unfortunately for California providers, Sedgwick is no worse off for their failure to adhere to the fee schedule and payment regulations.

Sedgwick forced this QME to not only spend $180 (which, despite orders from Maximus, claims administrators often fail to return to the provider); the QME also committed huge administrative time and resources to file hundreds of pages of documents — all to simply receive what was plainly owed.

Sedgwick held on to the QME’s reimbursement for 7 months, while playing IBR Chicken. Yes, the QME won the dispute, but Sedgwick is only out $180 for wasting provider and state resources (we won’t hold our breath for “self-executing” penalty and interest payments).

As we have written many, many times: California law incentivizes claims administrators to improperly reimburse providers. No consequences, no compliance.

Maximus IBR Decision

Since Sedgwick paid (albeit underpaid) following Second Review, the DWC allowed the dispute to proceed to IBR to determine exactly how much was owed.

Maximus concluded that MLFS billing code ML201 pays exactly $2,015, because it says so pretty clearly in the relatively simple MLFS. Maximus also calculated the appropriate amount due for record-review MLFS billing code MLPRR at exactly $3.00 per page, probably just by using the calculator on someone’s smartphone.

Maximus’ adjudication is below.

Of course, calculating reimbursement amounts is what Maximus does. Sedgwick, on the other hand, clearly needs the power of daisyWizard technology. But as we have demonstrated, it makes logical sense for Sedgwick to stay bad at math.

IBR Chicken is always a win for the claims administrator, even when they lose.

Med-Legal billing requires specialized expertise. daisyCollect professionals use our advanced software (and years of experience) to protect your practice. Request a demo below:

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