Claims administrators continue to innovate new techniques that make it harder for providers to receive proper reimbursement. In this installment, we tell a tale of the lengths to which The Zenith will go in order NOT to pay a provider.

In this version of a too-familiar story, The Zenith failed to correctly reimburse the provider on the initial bill submission, then denied the provider’s second review appeal. Finally, with only one recourse available, the provider filed a request for Independent Bill Review (IBR).

Upon notification of the provider’s request for IBR, The Zenith subsequently displayed an impressive misinterpretation of the IBR regulations to avoid reimbursing the provider correctly. Frankly, we’re disappointed by this, as The Zenith had been decent about following rules in the past but has recently demonstrated troubling payment issues.

All employers that use The Zenith as an insurer need to read this mangling of IBR rules with a critical eye, including Arden Group (Gelson’s Markets), Bristol Farms, Royal Oaks Farms, Sambrailo Packaging, etc. Refusing to properly reimburse physicians who treat injured employees cannot possibly properly reflect the mission of employers that use The Zenith.

Bait and Switch

On July 10 of this year, a provider submitted an IBR to Maximus to dispute incorrect payment from The Zenith for Procedure Codes 99205 and 99354. The additional reimbursement due for both disputed codes totaled $480.09.

On July 26, after reviewing the IBR request, The Zenith contacted the provider with a proposition. The Zenith would issue reimbursement using Procedure Code 90791 instead of 99205 and 99354. For 90791, The Zenith offered $215.86. In return, The Zenith requested the provider withdraw the IBR.

Wisely, the provider declined. As we’ve documented before, providers should NEVER NEVER agree to withdraw a request for IBR.

Then on July 31, The Zenith sent a 72-page packet to Maximus disputing the eligibility of the IBR, citing CCR §9792.5.7(f). Other claims administrators have used this tactic before.

CCR §9792.5.7(f) requires the provider to serve a copy of the IBR documents to the claims administrator:

• unless the documents were previously provided to or originated from the claims administrator, and
• as long as there is a description of the document and its date served

Fortunately, this provider used our DaisyBill technology and was able to quickly generate a compliant IBR which automatically included the following required documents per the regulation:

1. A written description of the documents along with the service dates of the documents and to whom they were sent
2. The completed IBR form
3. Proof of service by mail

With all the resources spent denying the original bill and appeal, attempting to negotiate downcoding, and finally preparing the 72-page IBR dispute, mailing it to Maximus, and serving a copy to the provider, certainly it would have been more cost-effective if The Zenith had reimbursed the provider correctly on the initial bill submission.

The Zenith Fails Employees

On September 27 Maximus issued the Final Determination Letter, overturning The Zenith’s original decision and ordering Zenith to pay the disputed amount as well as reimburse the $195 IBR filing fee.

On its website The Zenith advertises itself as “insurance for the California agriculture industry” and assures employers that The Zenith can be expected to “Put your employees first, to help anyone who is injured on the job get the medical care they need.”

The Zenith’s dogged refusal to correctly reimburse this provider is but one example of insurers using tremendous resources to deny payment, with the upshot of discouraging providers from helping injured employees.

DaisyBill helps providers obtain correct payment, even when the claims administrator is less than cooperative. Our Billing Software generates compliant Original Bills, and makes appealing for second review a snap. Plus, our IBR resources help your office prevail when it’s time to take the dispute to the state. Schedule a free demonstration today.

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