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).

In this, our fourth story on the fiasco of 2019 workers’ comp payments, we turn to the errors of Liberty Mutual. By now, from reading about Sedgwick, York, and Sedgwick (again), readers are familiar with the repeated payment abuses of providers by claims administrators.

Annually, DaisyBill processes millions of workers’ comp bills and historically Liberty Mutual has been one of the most cooperative and responsive claims administrators. Unfortunately, even one of the best claims administrators makes mistakes and Liberty Mutual’s systematic incorrect reimbursement is costing California providers dearly.

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 Sedgwick continues to apply an out-of-date fee schedule to the appeals, confounding providers’ good faith efforts to correct Sedgwick’s flagrant mistake.

Not one to avoid the spotlight, York Risk Services joins Sedgwick CMS in incorrectly applying the 2018 Physician Fee Schedule rates to services rendered in 2019. Our data show a consistent and demonstrated pattern of botched payments through at least the end of January.

Despite the vastly increased complexity of the California Physician Fee Schedule in 2019, most administrators are abiding by the changes and issuing checks for the appropriate amounts. A few stragglers remain who, for whatever reason, fail to follow the new schedule. Today, we turn our attention to York Risk Services.

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.

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.

Greetings to the DaisyBill blog readership! My name is James Carey and I’m happy to join the DaisyBill team as a staff blogger. Some of you may recognize me because we’ve worked together in the past, usually on the payer side of the equation.

For those of you who don’t know me, I am a 17-year industry veteran; I’ve worked as an adjuster and as a supervisor for workers’ comp insurance carriers, third-party claims administrators, and self-insured employers in California, as well as a consultant for entities across multiple jurisdictions.

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.