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