Even when there is potential payer fraud, California requires the provider -- not the payer -- to shoulder the burden of correcting claims administrator “mistakes.” For the thousands of bills that Zurich incorrectly denied, based on a completely shameful “misreading” of the Labor Code, providers must submit a timely Second Review appeal to dispute the denied reimbursement.

To add unsurprising insult to injury, in the recording we supply below, the Zurich representative tells a provider representative an incorrect way to appeal the incorrect Zurich denials.

WARNING: Following Zurich’s instructions will cut off the few legal avenues available to providers to collect for services already performed and billed. Under California law, despite this mess being Zurich’s fault, when a provider fails to properly submit a Second Review appeal, Zurich gets to keep the provider’s reimbursement.

To recap: Zurich mangled California laws and denied thousands of providers’ bills. Now providers throughout California must submit thousands of Second Review appeals to plead for Zurich to adhere to those workers’ comp laws it had previously “misunderstood.”

Zurich doubles down on its errors by instructing providers to submit a “formal letter” to dispute the incorrect denials. Contrary to Zurich’s directions, the correct path to appealing those denials is, of course, submitting a Second Review appeal. The failure of a provider to submit a timely and compliant Second Review appeal means that Zurich keeps the hijacked reimbursements.

Zurich’s Incorrect Appeal Instructions

When contacted, a Zurich representative offers noncompliant instructions for providers to dispute an incorrect payment. The transcribed recording of the conversation bears witness to the Zurich representative incorrectly instructing the provider to fax a “formal letter” explaining the reason for the dispute:

“The best way to have this taken care of is for you guys to send in a formal letter of an appeal, as stated on the EOR that you received. And we have a fax number that you can send it. Just attach any guidelines on your end that will show that your guideline is correct and our bill review’s guideline is incorrect to back up your dispute or to justify that your statement is correct in there and that the timely filing should be not the way the reviewers made their decision there.”

However, in the event Zurich denies the request in the “formal letter,” providers who follow these incorrect instructions will abdicate their rights to both filing for Independent Bill Review (IBR) and/or filing a lien. By listening to Zurich and skipping the required Second Review appeal, providers are barred from filing for IBR or lien to receive the correct reimbursement.

Note that this recording is the third we have posted, each from a different conversation.

Claims administrators (aka ‘payers’ or ‘carriers’ or ‘insurers’) know that the strict deadlines and daunting complexity of the appeals process will prevent many providers from seeking their incorrectly denied reimbursement.

Zurich is counting on the inability of the vast majority of providers to marshall the necessary resources to send timely and compliant Second Review appeals.

Timing Is Critical: Second Review Appeals Denied if Submitted After 90 Days

According to § 9792.5.5. Second Review of Medical Treatment Bill or Medical-Legal Bill, to dispute an incorrect reimbursement, the provider must submit a Second Review appeal to the claims administrator within 90 days of receipt of the Explanation of Review (EOR). If the provider fails to submit a compliant and timely Second Review appeal, then Zurich owes no further reimbursement to the provider.

Detailed Second Review Instructions to Follow on MONDAY 10/5/2020

In our next article, we will provide step-by-step instructions for filing a Second Review appeal in response to Zurich’s outrageous actions. In order to get paid, providers must observe not only the 90-day deadline, but also specific format and information requirements.

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