We don’t need further evidence that California workers’ comp is corrupted beyond any reasonable person’s notions of fairness, justice, or equity — but here’s Tristar Risk Management, not even pretending to comply with California workers’ laws and regulations for Second Review appeals.

The Third-Party Administrator (TPA) chooses to ignore providers’ Second Review appeals, failing to timely respond to these appeals per California Labor Code Section 4603.2(e)(3) which mandates that the claims administrator must “within 14 days of a request for second review…respond with a final written determination on each of the items or amounts in dispute.” (yes, Tristar is ignoring California law).

Between March 30, 2023, and June 14, 2023, daisyBill clients — in full compliance with Second Review regulations (promulgated by the Divisions of Workers’ Compensation (DWC)) — electronically submitted 302 Second Review appeals to Tristar to dispute incorrect reimbursements. Of those, Tristar has failed to respond to 278 (92%).

Further, in a conversation with daisyBill, a Tristar representative admitted that the TPA does not accept Second Review appeals electronically, even though California regulations (promulgated by the DWC) mandate providers submit these appeals electronically.

No one should hold their breath waiting for the DWC to take action regarding Tristar’s violations. After all, claims administrators ignoring laws and regulations is the state’s corrupt status quo.

Tristar Scoffs at Second Review Laws & Regulations

For providers, Second Review appeals are critical to obtaining correct reimbursement. Our data demonstrate that providers recovered over $111.5 million through Second Review appeals — revenue that claims administrators (like Tristar) would have kept if the providers had not submitted over 1.3 million appeals to dispute improper denials and adjustments.  

So exactly what happened to the 278 Second Review appeals submitted to Tristar by daisyBill providers between March 30, 2023, and June 14, 2023? daisyCollect contacted the TPA to determine the answer to that question.

On June 16, 2023 daisyCollect contacted Tristar to determine the payment status of a Second Review appeal submitted on May 17th – since almost one month had elapsed with no response.

Tristar’s representative claimed that the appeal was not on file. Incredibly, the representative also explained that Tristar does not accept Second Review appeals electronically. The representative instructed that daisyCollect should fax the appeal — because this TPA is apparently comfortable ignoring regulations promulgated by the DWC.

And why wouldn’t they? We’ve seen repeatedly that the DWC is unlikely to effectively discourage this kind of non-compliance. From there, the story got even worse.

Even though Tristar’s instructions directly contradicted DWC regulations, daisyCollect resubmitted the appeal via fax as requested. Nine days later, daisyCollect called Tristar again for a payment update. Tristar claimed the faxed appeal was not on file and instructed daisyCollect to submit the appeal a third time, via email.

When another week passed with no response from Tristar, daisyCollect reached out yet again, only to be told — you guessed it — the appeal was not on file. Moreover, the representative reported that Tristar was working on a backlog of Second Review appeals submitted as far back as March 31, 2023.

On July 7, 2023, daisyBill contacted Tristar for the fourth time, and left a message regarding the unpaid Second Review appeal originally submitted on May 17, 2023. The appeals representative has not responded as of this writing.

CA’s Corrupt and Crumbling Workers’ Compensation System

California workers’ compensation is a demonstrably corrupt environment, actively driving physicians from treating injured workers. It is impossible not to wonder if this is because the DWC:

• Allows claims administrators like Tristar to violate well-established laws and regulations requiring claims administrators to respond to electronic bills electronically.
• Allows claims administrators like Tristar to undermine the appeals process, violating further regulations and making it an uphill slog for doctors to demand correction of incorrect denials and adjustments.
• Promulgates regulations that arguably contradict the Labor Code allowing claims administrators to defer authorization and payment for newly injured workers.
• Advises newly injured workers to be ready to pay (or beg) for their own medical care in the event of a workplace injury.

The rules for claims administrators exist, but only on paper. In reality, the California workers’ compensation system as overseen by the DWC is a joke, with a cruel punchline in store for anyone injured on the job.

daisyBill makes workers’ comp billing easier, faster, and less costly. Request a free demonstration below.

REQUEST DEMO