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).

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 Sedgwick continues to apply an out-of-date fee schedule to the appeals, confounding providers’ good faith efforts to correct Sedgwick’s flagrant mistake.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

DaisyBill strives to make workers’ comp billing and payment smoother for both providers and payors.

We work with thousands of payors, including employers, insurers, and third-party administrators across California to electronically submit over 1.25 million compliant bills annually. We’ve seen good behavior and bad from payors. But we’ve never heard of a more frustrating experience than the one providers endure with York Risk Services — an experience we’ve endured ourselves.

When York fails to respond to bills for treating injured employees, providers report facing an infuriating uphill battle to track those bills. We strongly encourage medical billers to alert their providers about York’s unnecessary payment friction.

York can (and should) do better to help providers.

Bill review is very profitable. Sadly, that profit comes at the expense of other stakeholders in workers’ comp.

Bill review is a huge part of the workers’ comp billing and payment system, and a large source of revenue for third party administrators (TPAs). Everyone in work comp should understand that bill review companies and TPAs can unnecessarily drive up the cost of workers’ comp to serve their own bottom lines.

Here’s how.