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Statistics Prove Second Review Appeals FAIL Providers

March 27, 2019 by James Carey

Our previous articles highlighted claims administrators’ processing speed for original bill submissions. Now, we turn our attention to average days to process Second Review appeals.

Last year, to dispute an incorrect reimbursement or denied payment, DaisyBill clients submitted more than 123,400 Second Review appeals.

To dispute an incorrect reimbursement or denial, Labor Code §4603.2(e)(1) and 8 CCR §9792.5.5 require providers to submit Second Review appeals within 90 calendar days of receiving the original Explanation of Review (EOR). If the provider fails to submit the appeal within the allotted time frame, the bill is deemed satisfied and no further reimbursement is due.

Keep in mind that California 8 CCR 9792.5.5. requires a provider to transmit a Second Review appeal in the same manner as the transmission of the original bill. If the original bill was transmitted electronically, the Second Review appeal must also be transmitted electronically.

In turn, the Labor Code and regulations require the claims administrators to process a Second Review appeal within 14 calendar days of receipt of the Second Review appeal, regardless of the type of transmission (electronic or non-electronic). But unlike providers, who give up any right to further payment if they miss an appeal deadline, there are NO repercussions for the claims administrator that fails to timely process Second Review appeals.

Payers Incentivized to Ignore Second Review Requirements

The statistics below show multiple claims administrators, on average, fail to comply with the 14 calendar day processing deadline for these Second Review appeals. DaisyBill spoke with one claims administrator representative who admitted that there was no imperative to process these appeals.

This same claims administrator further explained that the  Labor Code 4603.6(a) incentivized them to ignore the Second Review appeals because the provider was not allowed to file an Independent Bill Review (IBR) request until the Second Review was processed. In other words, by ignoring the provider’s Second Review appeal, the claims administrator prevented the provider from advancing to the next level of appeal for correct payment.

Claims Administrator Appeals Processing Speed: Fastest to Slowest

The quickest and slowest claims administrators are identified below for their respective share of the volume of appeals processed in 2018:

Based on averages, three fastest claims administrators

  1. Keenan & Associates -- 7.5 days    
  2. The Zenith -- 7.7 days
  3. Gallagher Bassett -- 8.3 days

 

Based on averages, three slowest claims administrators

  1. Liberty Mutual -- 41.9 days
  2. AmTrust North America -- 26.3 days
  3. York Risk Services Group -- 25.1 days

Average Days to Process: 2018 California Second Review Appeals

Claims Administrator

% Appeals Volume

Average Days

Gallagher Bassett

19.2%

8.3

Sedgwick Claims Management Services

11.4%

11.5

State Compensation Insurance Fund (CA)

11.2%

11.3

Zurich Insurance North America

7.2%

13.5

York Risk Services Group

4.0%

25.1

Tristar Risk Management

3.4%

20.2

Liberty Mutual Insurance

2.6%

41.9

CorVel Corporation

2.5%

11.7

The Hartford

2.2%

12

The Zenith

2.1%

7.7

ESIS, Inc.

2.0%

12.8

Berkshire Hathaway Homestate Companies

2.0%

15.1

AmTrust North America

1.9%

26.3

Acclamation Insurance Management Services

1.6%

13.7

Travelers

1.5%

17

Keenan & Associates

1.4%

7.5

Los Angeles County Metropolitan Transit Authority

1.4%

18.5

City of Los Angeles

1.1%

13.8

Intercare Holdings Insurance, Inc.

1.1%

14.6

AIG Claims, Inc.

1.1%

18.8

On average, approximately 55% of administrators met the required 14-day processing requirement. But the workers’ comp system in California needs better mechanisms to enforce compliance with these and other deadlinces.

DaisyBill’s electronic billing software compiles data from each Second Review appeal processed for all 300+ claims administrators to which we submit. We track whether the appeal was denied, further payment made, denial reasons, and more. We share some of that information in our free interactive claims administrator performance database -- use it to search and filter by claims administrator name, as well as by Second Review appeal to see how a particular administrator stacks up.

Ready for simple, intuitive Second Review appeals that can be performed in just three clicks? See how easy it is with DaisyBill.

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