How to Organize a Collection Office under SB863 /Regulations www.workcompliens.com
How to Organize a Collection Office under SB863 /Regulations / WCAB / Part 1 IMR and IBR WCAB Process www.workcompliens.com Richard J Boggan JD The Basics of 2013 Laws (SB 863, DWC Regulations and WCAB Regulations and Decisions www.workcompliens.com Medical Necessity 1. Requests for Authorization (Form RFA) 2. Utilization Review 3. 30 Days to request IMR (Form) 4. Reasonable Reimbursement 1. 90 Days to request second review (form) 2. 30 days to request IBR (form) 3. Fee $335.00 4. Consolidate Fee Paid by Insurance Company Causation 1. Disputed Liability 2. Deferred from IMR or IBR 3. Lien filing Time 4. Lien Filing 5. Lien activation Fee 6. Burden of Proof WCAB Process Deferred to WCAB Liability Issue Deferred to WCAB Liability Issue 1. 2. 3. 4. Causation Medical Necessity Reasonable Reimbursements Urgency of time Requirements’ Back to IBR or IMR process if deferred after liability issue resolved Which Path to Take • Causation ---------------Lien • Medical Necessity-------IMR • Reasonable Reimbursement-IBR Causation / WCAB Lien Process Causation of injury affects MT (Medical treatment) (If cause of injury = 1% industrial, IW gets 100% MT needed to treat injury) Medical Necessity IMR Reasonable and Necessary to Cure or Relieve the Effects of the Industrial Injury • Requests for Authorization • Approved • Delay Deny of Modify • Request Independent Medical Reviewer Reasonable Reimbursement • Fee Schedule • Contract Rates • Second Review - 90 days • IBR Process -30 Days • Fee- $335.00 • Consolidate Each File Reviewed Causation Medical Necessity Medical Collections File Reasonable Payment Cases Admitted Cases • Independent Medical Review Process • Independent Bill Review Process Denied cases / Disputed Liability • WCAB • Lien Process Admitted Cases / Causation Admitted 1. Request for Authorization Form RFA Adjuster Can Authorize Defer to disputed Liability Issue Send through Utilization Review Admitted Cases / Causation Admitted 1. Utilization Review can Find treatment request reasonable and necessary (authorized) Delay, modify or deny If delay, modify or deny adjuster will send with UR IMR request form Provider / Injured worker has 30 days to request IMR. IMR Decision Establishes Medical Necessity Issues (if decision treatment reasonable and necessary) 1. Can appeal 20 days WCAB 2. If granted assigned to another IMR Issues Medical Necessity • • • • • • • Non-PTP Providers Emergency Physicians MPN issues UR Deferred Retrospective Review Partial Payment After Deferred Deferred to WCAB Authorized or UR or IMR Approved Medical Necessity Established • Cannot rescind or modify authorized treatment after it has been provided based on the authorization • May have to go to IBR is not paid reasonable after billing • Adjuster cannot raise of treatment outside MPN if treatment was authorized. • Cannot defer IBR reasonable issues to lien as treatment authorized except applicability of PPO contract • IBR is an efficient, non-judicial process for resolving medical treatment and medical-legal billing disputes where the medical provider disagrees with the amount paid by a claims administrator on a properly documented bill after a second review. Admitted Injuries Reasonable Reimbursement IBR Process • How the Process Works • If Authorized or IMR Determined Reasonable cannot defer to Lien even if adjuster states outside MPN Reasonable Reimbursement Issues • • • • • • • Billed Payment or Partial Payment with EOB Request 2nd review 90 days Request IBR 30 days Fee $335.00 Consolidate Appeals Consolidate IBR Requests § 9792.5.12. (c) Two or more requests for independent bill review by a single provider may be consolidated if the Administrative Director or the IBRO determines that the requests involve common issues of law and fact or the delivery of similar or related services. PROVIDER MAY CONSOLIDATED IBR REQUESTS § 9792.5.12. (c) (1) Requests for independent bill review by a single provider involving multiple dates of medical treatment services may be consolidated and treated as one single independent bill review request if the requests involve one injured employee, one claims administrator, and one billing code under an applicable fee schedule adopted by the Administrative Director, or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11, and the total amount in dispute does not exceed $4,000.00. § 9792.5.12. (c) (2) Requests for independent bill review by a single provider involving multiple billing codes under applicable fee schedules adopted by the Administrative Director or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11, may be consolidated with no limit on the total dollar amount in dispute and treated as one request if the request involves one injured employee, one claims administrator, and one date of medical treatment service. § 9792.5.12. (c) (3) Upon a showing of good cause and after consultation with the Administrative Director, the IBRO may allow the consolidation of requests or independent bill review by a single provider showing a possible pattern and practice of underpayment by a claims administrator for specific billing codes. Requests to be consolidated under the subdivision shall involve multiple injured employees, one claim administrator, one billing code, one or multiple dates of service, and aggregated amounts in dispute up to $4,000.00 or individual amounts in dispute less than $50.00 each. 1 of 3 PROVIDER MAY CONSOLIDATED IBR REQUESTS § 9792.5.12. (c) (1) Requests for independent bill review by a single provider involving multiple dates of medical treatment services may be consolidated and treated as one single independent bill review request if the requests involve one injured employee, one claims administrator, and one billing code under an applicable fee schedule adopted by the Administrative Director, or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11, and the total amount in dispute does not exceed $4,000.00 1. single provider 2. multiple dates of medical treatment services 3. one injured employee 4. one claims administrator 5. one billing code under an applicable fee schedule adopted by the Administrative Director, or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11 6. total amount in dispute does not exceed $4,000.00 2 of 3 PROVIDER MAY CONSOLIDATED IBR REQUESTS § 9792.5.12. (c) (2) Requests for independent bill review by a single provider involving multiple billing codes under applicable fee schedules adopted by the Administrative Director or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11, may be consolidated with no limit on the total dollar amount in dispute and treated as one request if the request involves one injured employee, one claims administrator, and one date of medical treatment service. 1. single provider 2. multiple billing codes under applicable fee schedules adopted by the Administrative Director or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11 3. no limit on the total dollar amount 4. one injured employee 5. one claims administrator 6. one date of medical treatment service. 3of 3 PROVIDER MAY CONSOLIDATED IBR REQUESTS § 9792.5.12. (c) (3) Upon a showing of good cause and after consultation with the Administrative Director, the IBRO may allow the consolidation of requests or independent bill review by a single provider showing a possible pattern and practice of underpayment by a claims administrator for specific billing codes. Requests to be consolidated under the subdivision shall involve multiple injured employees, one claim administrator, one billing code, one or multiple dates of service, and aggregated amounts in dispute up to $4,000.00 or individual amounts in dispute less than $50.00 each. 1. 2. 3. Upon a showing of good cause single provider showing a possible pattern and practice of underpayment by a claims administrator for specific billing codes 4. involve multiple injured employees 5. one claim administrator 6. one or multiple dates of service • aggregated amounts in dispute up to $4,000.00 or individual amounts in dispute less than $50.00 each. Elements of a Reimbursement File Causation WCAB Medical Necessity IMR Reasonable Reimbursement IBR WCAB Now at the WCAB for files that fall under SB 863 in disputed liability issues cases the lien claimant has to only prove causation then the file would go back to the IMR – retrospective review if causation established or back to the IBR – to establish reasonable reimbursement is these are still at issue WCAB Procedures Summary • • • • • • • Time to file Liens Lien Filing Fee Lien Activation Fees Evidence Discovery 10770 10770.1 How to Organize a Collection Office under SB863 /Regulations / WCAB / Part 1 IMR and IBR WCAB Process www.workcompliens.com Richard J Boggan JD
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