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).

Reimbursements for CPTs 99358 & 99359 are tricky because payers frequently deny reimbursement for services that are not face-to-face with patients. Previously, we presented the hard data on payers who didn’t reimburse for these CPTs in 2017.

For 2018, we found 77 relevant Independent Bill Review (IBR) decisions; 42 of which overturned the payer’s denial of these CPTs. In these decisions, the provider’s documentation sways Maximus. The remaining 35 instances where Maximus upheld payer denials cite insufficient evidence or service is captured by another code.

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.

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.

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.

Recently DaisyBIll providers reported receiving incorrect and very confusing denials from MedRisk, a managed care provider network, for bills that were actually submitted directly to AIG. The MedRisk denials state: “Not currently a participating MedRisk provider. Please submit bill directly to insurance carrier.”

But in every reported incident, the providers had submitted the denied bills directly to AIG, the correct carrier for the particular patient and injury.