Blog: DaisyBill News

It’s SCIF’s turn. The California State Compensation Insurance Fund (SCIF) is also incorrectly reimbursing providers using the 2018 Physician Fee Schedule instead of the correct 2019 version.

We’re now in the fourth installment of our continuing series on the seemingly systematic underpayment of bills by some of the largest payers in California’s workers’ compensation system.

Each of the four payers exposed in this series -- Sedgwick, York, Liberty Mutual, and now SCIF -- used the 2018 fee schedule to underpay what may be untold tens of thousands of bills for 2019 dates of service (DOS).

Late bills will not be paid. Period.

Timely billing has been in effect in California workers’ compensation since January 1, 2017, but we still see providers missing this all-important deadline. The passing of Senate Bill 1175 introduced a billing deadline for all medical and medical-legal services of one year from date of service (DOS).

Correcting a coding error is as simple as submitting a Second Review appeal explaining the error.

Last year, we discussed the convoluted process to correct billing errors. As we demonstrated, fixing a billing coding error is a frustrating process, at best.

 In the case of a missing CPT code, providers can submit a new bill with the missing CPT code.

But what about situations where the original bill contains a coding error? For example, a missing modifier?

Sedgwick’s payment mistakes multiply. First, Sedgwick incorrectly paid California providers by applying an old workers’ comp fee schedule. Now Sedgwick compounds its error by denying appeals of those incorrect payments.

As we reported recently, Sedgwick incorrectly applies the 2018 Physician Fee Schedule to workers’ comp bills for 2019 dates of service. This means providers must file Second Review appeals to seek correct payment. Unfortunately, Sedgwick is also mangling these appeals. Sedgwick continues to apply an out-of-date fee schedule to the appeals, confounding providers’ good faith efforts to correct Sedgwick’s flagrant mistake.

When navigating the seas of change, it’s refreshing to find an island of relative stability. Like California’s state-specific codes, the splinting and casting codes group (commonly referred to as “Q codes”) is not subject to the Geographic Practice Cost Index (GPCI) adjustment and is only adjusted quarterly with the DWC adoption of the Medicare rates.

Time to start counting your poultry -- State Farm’s workers’ compensation henhouse is now guarded by the third-party administrator (TPA) Sedgwick, effective October 21, 2018. Prior to this change, State Farm managed the administration of its workers’ comp claims.

With the flurry of new year fee schedule changes, California updated the Physician Fee Schedule reimbursement for its state-specific codes. These codes are explained in 8 CCR §9789.12.14 by the Division of Workers’ Compensation (DWC) and reimbursement is updated annually. Thankfully, the reimbursement formula is straightforward and not subject to variation by locality.

In the Physician Fee Schedule, the state-specific codes cover services for which there are no appropriate CPT codes, such as the Primary Treating Physician’s Progress Report (DWC form PR-2). Annually, the California DWC establishes a single new statewide reimbursement for each of the services covered by these ‘WC’ codes.

Since the beginning of 2019, Sedgwick CMS has incorrectly used the 2018 Physician Fee Schedule to reimburse providers. Our data indicates that Sedgwick is consistently and incorrectly reimbursing providers for 2019 dates of service.

While the California Physician Fee Schedule is infinitely more complex in 2019, many claims administrators are correctly reimbursing providers. But some are not.

On a regular basis, this blog will bring to light the claims administrators that repeatedly and non-compliantly reimburse providers the wrong amount for services rendered in 2019. Today, we commence with Sedgwick.