In our experience, Sedgwick Claims Management Services, Inc. isn’t known for consistently paying providers correctly or adhering to California payment laws and regulations.

But when Independent Bill Review (IBR) overturns one of Sedgwick’s improper reimbursement reductions and orders the Third-Party Administrator (TPA) to pay up, is it too much to ask for compliance?

Sedgwick improperly downcoded a provider’s bill for Evaluation and Management (E/M) services to a Walmart employee, knocking reimbursement down despite the attached reports clearly documenting the justifications for the charges as billed. When the provider submitted a Second Review appeal, Sedgwick again denied the correct payment.

With no other choice, daisyCollect assembled the necessary paperwork and ponied up $195 to request IBR. Maximus, the state’s independent reviewer, smacked down Sedgwick’s downcoding and ordered the TPA to pay the correct amount (plus $195 for the IBR filing fee).

That was in November of last year.

Sedgwick still hasn’t satisfied this bill, as of this writing in August of 2026, making this one of the longest post-IBR non-payments daisyCollect has ever seen.

It’s an egregious example of the impunity with which Sedgwick (and other payers, but none with Sedgwick’s scale and frequency) violates the rules and stiffs or underpays providers. Sedgwick will probably face no consequences whatsoever.

A Long, Long Road to a Dead End

The provider rendered treatment to the Walmart employee all the way back in March 2025.

Upon receiving the provider’s bill, Sedgwick downcoded CPT code 99215 for 40+ minutes of E/M services to 99214, a code providers use for a maximum of 39 minutes of E/M services. Instead of paying correctly, Sedgwick forced the provider to dispute the underpayment, twice refusing to pay correctly until the provider finally requested IBR in July 2025.

The California Division of Workers’ Compensation (CA DWC), by law, has to assign disputes to Maximus for review within 30 days of receiving the provider’s IBR request. But this is California, where the state agency responsible for upholding provider and injured workers’ rights routinely flouts the law. Acting entirely consistently, the dispute wasn’t assigned until September 2025, 49 days after the request.

Another 49 days later, on November 6, 2025, Maximus handed down its ruling (Maximus adhered to the law, which grants the reviewer 60 days to render a decision once the CA DWC assigns the dispute). Maximus’s Final Determination (below) made clears that the documentation the provider included with the bill supported 99215.

Maximus ordered Sedgwick to pay the disputed reimbursement amount and the $195 filing fee within 45 days, making December 21, 2025 the due date for Sedgwick to settle up.

As of this writing, Sedgwick hasn’t sent another dime, 500 days from the day the provider sent the bill, 291 days since Maximus issued its decision, and 246 days since the official deadline for Sedgwick to comply.

Even if Sedgwick eventually pays the disputed amount, history suggests the provider will likely not receive the significant penalty and interest payments owed, nor the filing fee. But, even if Sedgwick paid every cent it owes, for a provider to have to devote this much time and administrative resources to a single bill is a terrible sign.

Major health systems are opting out of workers’ comp, along with countless small practices, because of nonsense like this. The CA DWC has the power to enforce payment rules and IBR decisions, deter abuse with appropriate penalties, and give providers a reason to stay in the system.

…but we’re not holding our breath.

daisyBill lets providers submit instant payment appeals and includes tools for easier IBR requests. Click below to learn more:

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