Some claims administrators treat California workers’ comp laws and regulations as optional — and there may be no more egregious example than Sedgwick Claims Management Services.

The Third-Party Administrator (TPA) has a long record of non-compliance, detailed on this blog and immortalized in over 100,000 Audit Complaints filed to report Sedgwick’s violations.

In a disputed claim for a Santa Cruz County Central Fire District firefighter, Sedgwick failed to pay for an initial comprehensive and subsequent supplemental Medical-Legal evaluation which Sedgwick’s attorney requested.

The Agreed Medical Evaluator (AME) submitted the bill for the Comprehensive Medical-Legal Evaluation in February 2023, and the bill for the Supplemental Evaluation in April 2023. Absurdly, as of this writing (in August), a Sedgwick representative continues to assert there is no claim on file for the injured firefighter.

As the details below demonstrate, this AME has no choice but to hire an attorney to collect the payments owed for these evaluations — a tremendous burden on both the AME and the Workers’ Compensation Appeals Board (WCAB).

Unfortunately, this incident exemplifies how Sedgwick treats its responsibilities to employers and injured workers. As a self-insured employer, the Central Fire District of Santa Cruz County should be:

1. Outraged by their own TPA’s failure to comply with California law, and
2. Concerned whether Sedgwick mistreats Central Fire District employees and the doctors who care for them

This is not a functioning workers’ compensation system. It is a system off the rails, with little to no enforcement of laws and regulations. Consequently, injured workers’ return to work is likely delayed while employers’ costs soar.

Sedgwick Denies Claim, Requests Med-Legal Evaluation

According to the Central Fire District’s Human Resources department, Sedgwick initially denied the firefighter’s claim in March 2022. In December 2022, the attorney formally requested a Medical-Legal evaluation from the AME.

On January 9, 2023, the AME conducted the evaluation as requested.

Sedgwick accepted the claim in March 2023 (that’s right, a year after the initial denial). Also in March, the attorney for Sedgwick requested a Supplemental Medical-Legal Evaluation to “clarify two issues.”

Sedgwick Disregards AME Bills

California Code of Regulations Section 9794(b) dictates claims administrators must pay Medical-Legal bills within 60 calendar days:

“All medical-legal expenses shall be paid within 60 days after receipt by the employer of the reports and documents required by the administrative director unless the claims administrator, within this period, contests its liability for such payment.”

The AME submitted the bill for the Comprehensive Medical-Legal evaluation on February 1, 2023; therefore, Sedgwick owed the AME payment and an Explanation of Review (EOR) by April 2, 2023. 

After the payment deadline came and went, on April 5th daisyCollect contacted Sedgwick. The Sedgwick representative could not locate the firefighter’s claim or any information regarding the AME’s bill. The Sedgwick representative suggested contacting the employer to verify the claim information.

As instructed, daisyCollect contacted Santa Cruz County Central Fire District. A representative confirmed the firefighter’s claim was accepted and that all information reported on the bill sent to Sedgwick was correct. daisyCollect sent a duplicate bill for the AME evaluation.

When daisyCollect contacted Sedgwick (again) with the claim information verified, Sedgwick could not locate any information about the firefighter’s claim. daisyCollect reached out multiple times thereafter to Sedgwick — all to no avail.

Sedgwick also failed to respond to the AME’s bill for the supplemental evaluation requested by Sedgwick's attorneys. Again, daisyCollect contacted Segwick repeatedly. And again, Sedgwick offered nothing but ¯\_(ツ)_/¯ and suggestions to contact the employer (again).

A complete timeline of our (so far unsuccessful) efforts to obtain payment on behalf of the AME is documented below.

In what kind of functioning system can claims administrators ignore bills and claim no knowledge of an obligation to pay?

In what kind of functioning system do providers have to hire attorneys simply to be reimbursed for services requested and rendered?

Why are attorneys and the WCAB relegated to acting as a collection agency on behalf of AMEs?  

In what kind of functioning system is daisyBill, on behalf of the AME, forced to file our 132,759th and 132,760th Audit Complaints against Sedgwick for its consistent, continued non-compliance?

This non-compliance drives providers from treating injured workers, drains employer dollars, and keeps injured workers from getting the care they deserve.

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