We are writing about Zurich again, as the claims administrator’s conduct continues to be a symptom of the deep unfairness that permeates California’s workers’ comp system. That Zurich can circumvent all of the “proper” mechanisms that SB 863 put in place, apparently without fear of penalty or consequence, exposes how the system allows payers to cheat California providers who treat injured or sick workers.

Today, we publish an emergency article with three recordings of Zurich representatives to demonstrate:

1. Zurich’s continuing denials of Second Review appeals submitted by providers to dispute incorrect reimbursement denials.
2. Zurich representatives’ incomprehensible, nigh chaotic, nonsense responses to providers who are simply trying to receive reimbursement for services already rendered.
3. The herculean efforts required by a single Primary Treating Physician (PTP) to receive payment from Zurich for a single bill for seeing an injured worker.

Last week, we wrote an article explaining how Zurich is denying Second Review appeals that were submitted by providers to dispute the originally incorrect Zurich bill denial: Zurich Triples Down on Foul Play.

Zurich’s noncompliance is affecting providers throughout the entire California workers’ compensation community. To date, Zurich has incorrectly denied 700+ bills submitted just by DaisyBill clients and Zurich is doubling down on its misdeeds by denying Second Review appeals. These Zurich appeal denials mean that DaisyBill providers will be forced to pay collectively over $126,000 to file 700+ Independent Bill Review applications with Maximus.  

The sheer scale of Zurich’s malfeasance and shady behavior shows that the failures of SB 863 enrich payers while inflicting harm to providers who actually treat California’s injured workers.

Provider Sends Zurich a Simple and Compliant Bill

In this example, the PTP followed each of the required steps to receive payment for evaluating an injured worker.  Zurich denied both of the provider’s requests for reimbursement:

1. 8/24/2020 - Original bill submitted for a 5/15/2020 date of service. Total due per the California Official Medical Fee Schedule (OMFS) $121.44.
2. 8/31/2020 - Zurich denies reimbursement for Original bill services. Zurich incorrectly states the provider submitted an untimely bill. We earlier outlined why this denial is based on a reading of the Labor Law that is completely wrong.
3. 10/5/2020 - Second Review appeal submitted by provider to dispute the incorrect denied reimbursement.
4. 10/14/2020 - Zurich denies reimbursement of the Second Review appeal. Zurich EOR incorrectly states the Second Review appeal was a duplicate bill.

By denying the Second Review appeal, Zurich forces the provider to pay $180 to file for Independent Bill Review (IBR) by Maximus. According to California Labor Code 4603.6 the IBR must be filed within 30 days of the date of receipt of the explanation of review: “If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment.”

Zurich Misleads Provider Into Surrendering IBR Rights

The following 11:27 minute recording represents the utter chaos and misdirection (with some tragicomic ineptitude thrown in) that Zurich inflicted on a provider -- who is simply trying to figure out the next step after Zurich denied the Second Review appeal as an exact duplicate.

In the recording the Zurich representative issues the following conflicting and confusing claims and instructions:

2:04         Zurich received and denied the Original bill

2:40         Second Review appeal not on file with Zurich

3:48         Zurich received Second Review appeal

5:05         Zurich has not processed Second Review appeal

7:34         Provider should disregard the denied Second Review appeal

8:40         Second Review appeal denial due to Zurich ‘system error’

9:39         Payment will be expedited

10:15         Payment is not guaranteed only reprocessing will occur

11:09         Two weeks required for reprocessing of the appeal

As Zurich waffles on the details, Zurich is eventually forced to admit to more Zurich system errors. For anyone listening to this conversation, it’s difficult not to draw the conclusions that:

1. The Zurich representative is using systems and technology that cannot locate the correct details about any given bill or appeal,
2. Noncompliance is Zurich’s preferred language, and
3. By telling providers that Zurich will reprocess their appeals, thereby inducing providers to not file IBRs and forfeit any chance at further appeals, Zurich is the only one who wins.

We chose not to edit this recording, other than to block identifying information, to show the extent of the torture inflicted on providers trying to get a simple answer to a question about an appeal.

Zurich Chaos and Torture Magnified

For those with masochistic tendencies, below are two additional recordings where different Zurich representatives offer completely different and conflicting information about the same simple and compliant bill and subsequent denied Second Review appeal.

• Zurich Recording #2: 8:50
• Zurich Recording #3: 12:33

It is both unfortunate and inconceivable that this is how California allows claims administrators to torment providers who treat injured or sick workers. This provider has very little recourse, except to cease treating Zurich patients.

For DaisyBill clients, DaisyBill will be submitting Second Review appeals for incorrectly denied Zurich reimbursements and we will be filing IBRs for all denied bills for all DaisyCollect clients. We refuse to allow Zurich’s appalling conduct to be unanswered, much less rewarded by its retention of the reimbursements owed to providers.

The sad truth is that Zurich will mislead and victimize providers throughout the state, and Zurich will be richer for what increasingly looks like its intentional perversion of California laws and regulations (the same laws and regulations that, at the end of the day, offer no protection to providers).

https://www.merriam-webster.com/dictionary/fraud

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