Workers’ comp insurer The Hartford has a few very basic things to learn about Medical-Legal evaluations in California.

Namely, that initial evaluations generally precede supplemental evaluations — and that reviewing the contents of a physician’s bill submission should generally precede issuing a payment denial.

The Hartford refused to pay for the supplemental evaluation in question by claiming that the Qualified Medical Evaluator’s (QME) charges were not payable “without conducting an initial medical-legal evaluation.” This despite the fact that the QME included the initial comprehensive evaluation report with the bill.

The Hartford stood by its deeply flawed assertion upon Second Review, and subsequently claimed the dispute was not eligible for Independent Bill Review (IBR) because charges for a supplemental evaluation are “disallowed when not billed with initial codes.”

Fortunately, daisyCollect was there to wade through the hogwash on this QME’s behalf — an unfortunate necessity in a state where nonsensical denials like this have a genuine chance of saving the claims administrator money at the QME’s expense.

The Hartford Denies Payment for Eval The Hartford Requested

In July of 2022, the QME conducted a Comprehensive Medical-Legal Evaluation to help resolve a dispute between The Hartford and an injured worker. Less than two months later, The Hartford sent the QME additional records to review for a Supplemental Medical-Legal Evaluation, as evidenced by the required attestation letter below.

But when the bill came for the supplemental evaluation, The Hartford refused payment on the grounds that the billing code for a supplemental evaluation (ML203) is not payable without an initial evaluation.

The Hartford Denies Payment…Again

On the QME’s behalf, daisyCollect submitted a Second Review appeal, in the fanciful hopes that The Hartford would recognize its own supremely defective bill review and pay without further waste of time and resources.

For good measure, daisyCollect included with the SBR-1 form  1) the original bill submission, 2) documentation of the initial evaluation, and 3) a similar previous IBR case as an example of The Hartford’s incorrect adjudication.

Despite daisyCollect patiently leading it to water, the proverbial horse refused to take a single sip. The Hartford stood by its original denial, citing the same strange reasons.

The Hartford Argues Against IBR Eligibility

The Hartford’s second payment refusal forced daisyCollect to do exactly what the SBR-1 form indicated: request IBR from the state.

There was surely no need for The Hartford to further demonstrate its ineptitude. But as they say, fish gotta swim.

In a last-ditch effort to avoid paying for the service they requested, The Hartford claimed to the Division of Workers’ Compensation (DWC) that the dispute was not eligible for IBR because…well, it would pain the daisyNews Team too much to type it again.

The Hartford’s letter to the DWC is below.

It’s difficult to grasp how laughable the notion of billing ML203 for a supplemental evaluation “with initial codes” really is. Only one kind of Medical-Legal evaluation can be “initial” according to the Medical-Legal Fee Schedule (MLFS): a Comprehensive Medical-Legal Evaluation (ML201), the description of which begins as follows:

“Includes all comprehensive medical- legal evaluations that do not qualify as follow-up or supplemental medical- legal evaluations.” [emphasis added]

Is The Hartford suggesting billing ML203 and ML201 together? That’s fairly preposterous, given that a Supplemental Medical-Legal Evaluation can only occur “...after receiving a request for a supplemental report from a party to the action or receiving records that were not available at the time of the initial or follow-up comprehensive medical-legal evaluation.”

This is workers’ comp in California, and this is why qualified physicians willing to help resolve disputes are becoming harder and harder to find.

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