Blog: Daisy News

When the Independent Bill Review (IBR) process overturns a claims administrator’s incorrect denial or adjustment, the claims administrator is legally bound to timely pay what they owe. That payment must include both the correct reimbursement for the original bill and the $195 IBR fee the provider paid to initiate the appeal.

Claims administrators have 45 days to comply with the IBR decision and pay in full.

Unfortunately, Tristar chooses to ignore these payment requirements in an act of blatant non-compliance. Sadly, there is no recourse for the provider except to continue to beg for Tristar’s compliance.

California regulations mandate that when Independent Bill Review (IBR) overturns a claims administrator’s incorrect bill denial or adjustment and finds in favor of the provider, the claims administrator must reimburse the provider for the $195 IBR filing fee, in addition to the disputed amount owed.

Unfortunately certain claims administrators, including TriStar Risk Management, Protective Insurance, and Acclamation Insurance ignore this important rule, forcing providers to go to preposterous lengths to recover the full amount due.

An industry study tells an interesting story about workers’ compensation claims. A significant upward trend in denials ultimately cost employers and their claims administrators revenue. That’s because about 67% of claimants nationwide eventually prevailed over such denials, despite the resources claims administrators devoted to denying the claims.

With such a huge percentage of denials converting to paid claims, the administrative and legal costs claims administrators incur represent something sadly typical of workers’ comp: pointless waste.

Repeatedly, we hear some version or another of the same story: a provider reaches out to a claims administrator for information regarding workers’ comp billing and payment. The claims administrator provides information that turns out to be false, misleading, or irrelevant.

The provider then finds themselves out of compliance, or denied reimbursement, or both.

The reality is that providers have to look out for themselves. Providers must seek education on workers’ comp rules and regulations in their state — because claims administrators can’t possibly know the rules in every state.

Broadspire, a global third-party claims administrator (TPA), incorrectly denied several bills for the treatment of an injured worker. While incorrect denials are nothing new in California workers’ comp, one thing makes this situation even more egregious: by Broadspire’s own admission, the denied bills were still in process.

What’s more, the usual billing and payment process is further complicated by the provider’s inclusion in a network. As this situation demonstrates, the benefits of participating in some networks are dubious at best — especially considering the payment hassle networks can create.

Effective May 1 of this year, insurers Allianz and Fireman’s Fund Insurance Company (FFIC) merged their payment systems for California workers’ comp to reflect Allianz’s 2015 acquisition of FFIC. As part of this transition, Allianz established two new electronic billing payor IDs for all claims, including those claims formerly administered by FFIC.

For electronic billing, Allianz and FFIC previously used two separate payor IDs. Effective May 1, 2018 Allianz continues to use two payor IDs; the correct choice of payor ID is dependent on the Date of Injury (DOI) for the claim in question.

We recently warned providers about an emerging trend among California workers’ comp claims administrators: denying payment for Evaluation and Management (E/M) services in the absence of extensive reports. Claims administrators often downcode such E/M services, but outright denials are increasingly common — and upheld by Independent Bill Review (IBR).

Gallagher Bassett is one claims administrator consistently supplying examples of this “zero tolerance” policy. Providers billing Gallagher Bassett, take heed.

Most claims administrators lack the technology to process electronic bills from providers. Instead, these claims administrators rely on clearinghouses. Since DaisyBill has direct access to all 5 California clearinghouses, we’re uniquely qualified to evaluate and compare the performances of each. With this series, we take a look at the value each clearinghouse adds to (or subtracts from) workers’ comp.

To kick this clearinghouse series off, we’ll start with the most efficient kind of clearinghouse: no clearinghouse at all.

Corvel Corporation is not a clearinghouse, per se. But CorVel is something even more important: a claims administrator that essentially functions as its own clearinghouse, directly accepting and processing providers’ electronic bills. This vastly reduces complications and potential friction for providers and employers, both of whom benefit from CorVel’s integrated approach.

We applaud any time a claims administrator’s practices make things simpler for all concerned. By taking on the duties of a clearinghouse, CorVel sets a new standard of efficiency.