Recently, several clients have reported Sedgwick refusing to pay PR-2 reports when billed with a reimbursable prolonged service code (such as a 99354).In each case, the primary treating physician issued the PR-2 and each conformed to PR-2 regulations regarding timing. When clients inquired into the reason for the PR-2s denials when billed with the prolonged service code, Sedgwick representatives stated it was due to the “RBRVS regulations that went into effect on January 1st”.

After we verified the regulations don’t specify anything against billing these codes together, DaisyBill reached out to Sedgwick directly. After several calls and escalation to a supervisor, we were told that their internal system indicated that denial was justified because of a statement made by Sue Honor in one of her seminars. According to Sedgwick, Sue Honor works for the state--she doesn’t but she used to-- and most people in the California workers’ comp community (including ourselves), know her as a very knowledgeable and helpful source of information. Additionally, Sedgwick incorrectly interpreted Sue as saying that PR-2 is not payable when billed with a prolonged service code.  We informed the Sedgwick representative that a) Sue does not work at the state and hasn’t in several years, and b) Sedgwick’s interpretation of her statements was not correct and we would reach out to Sue directly for confirmation.

An email from Sue confirmed that she never said that PR-2s are not reimbursable under the above circumstances.  Sedgwick requested that this be sent to them to forward to the compliance department. On Friday, December 5th, a representative from Sedgwick confirmed that they would be revising their adjudication system and stated that previous incorrectly processed bills should be submitted for Second Bill Review.

Providers, do you have any bills where this has occurred? Be sure to file a second bill review within 90 days of receipt of the EOR.  

Do you ever receive questionable reasons as to why a bill was not paid? Please share with us, we’re happy to research for you and share the knowledge with the DaisyBill community.

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