2017 newsletter provider issues

2017 Collections Dispute Newsletter www.workcompliens.com Page 1

WC: Summary of

California Workers'

Comp System for

Providers Explained in

Steps -- Including

Advantages Taken By

Both Parties

1. Independent

Medical Review (IMR)

Process Includes, the

request for authorization,

utilization review, IMR

process all based on

medical necessity based on

MTUS and overshadowed

by evidence based

medicine (EBM)

2. Transitional arrow

to next step

3. Starts by

Submitting Request for

Authorization form (RFA):

This is done by form for

dates of services 2013 on

forward except for the first

part of 2013 if date of

injury prior to 2013. Prior

to 2013 a PR2, Narrative

report, or document

shown on top, for a

request for authorization,

and initial report. Only a

treating physician can

request authorization, this

causes some problems

with the Defense as they

are shown a RFA by an

Ancillary Provider and

see no UR so they buy the

argument of untimely

UR, which is wrong, if

not proper request by

proper party no need to

respond. Second issue is a

RFA cannot be by a

electronic signature or cut

and paste signature unless

by consent by the

insurance. All services

must have a RFA, trying

to by-pass this process,

means the Insurance does

not have to pay for those

services. In addition a

Ancillary can get the

results of a UR by an

INSIDE THIS ISSUE:

PROCEDURAL PROCESS IMR, IBR AND WCAB

2017 WORKERS’ COMPENSATION LIEN

CLAIMANT COLLECTIONS NEWSLETTER SUBSCRIBER FOR COLLECTIONS NEWSLETTER

2017 Collections Newsletter For more News and Educational Materials Visit www.workcompliens.com

Richard J Boggan JD Juris Doctor, Law publisher of "Work Comp Collections Newsletters “Author of “Lien Claimants’ Representative Guidebook” published each year since 2001

2016 A-Z all Provider Issues IBR, IMR and

WCAB Decisions Plus SB 1160 Petitions and

Responses Evidence Based Medicine book for

every service, medication, DME, surgery, testing,

referrals and more, done in the same format as

below now available 3 years in the making see

below picture sample that is done for all

services, medication, DME, surgery, testing,

referrals and more

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(72 hours or less)

3.Retrospective (30

days or less)

18. Transitional

arrow to next step

19. After UR

Process if denied,

modified Adjuster will

send request for IMR

form filled out by

adjuster to the applicant

or the applicant

representative, it is the

obligation of the

adjuster to make sure

all medical reports are

submitted. 30 day to

submit. At the start of

2013, Applicant

Attorneys, would ask

the PTP to help submit

the IMR, but few did so

the practice stopped.

The only exception to

who can submit an IMR

is an emergency room

physician who can

submit one without the

applicant. ( after a UR

denial of retrospective

review)

20. Blank

21. Transitional

arrow to next step

22. Transitional

arrow to next step

23. 30 days to

request an IMR fees

paid by Adjuster /

Insurance Company (all

filed out sometimes, but

a Provider can add a

report if all parties

served before or at the

same time submitting.

24. Transitional

arrow to next step

25. 1.Goes to

Director if eligible goes

to IMRO 2.Assigned to

IMR 3.Issues decision

4.May appeal in 20

days to WCAB

26. UR has a life

insurance is prohibited

from sending them the

complete UR as it puts

forth protected medical

information, even though

it’s done today, they are

charged with getting the

results from the PTP, or

treating Provider. ( see

definition of physician

under regs)

4. Transitional

arrow to next step

5. Adjuster has to

notify in 5 days if

incorrect form: if the

Provider uses an

incorrect form and it is

clear it is a RFA by title

of page and all required

information to do a UR,

the insurance has 5 days

to reject that improper

form, or it is deemed

accepted. NOTE: Unlike

the IBR process, a

untimely response to a

UR request does not

establish medical

necessity, there is only

one default that

establishes medical

necessity and that is

when there is a partial

payment within 30 days

for a RFA ( this is

usually found in

requests for

retrospective review) ,

all other issues medical

necessity is always on

the Provider to

establish. 6. Transitional

arrow to next step

7. Adjuster Actions

8. Transitional

arrow to next step

9. Not send it

through utilization review

because disputed liability

issue –goes to lien

process -deferred- This

regulation was intended to

take even denied case later

admitted away from the lien

process in keep it in the IMR

process, which means that

after a court order or by

agreement that a denied case

first denied is admitted, if

services provided the

adjuster was to do a

retrospective review without

any action by the Provider.

This helps Providers in some

cases if they did not file a

lien and was past the time to

file. In addition, it is

important to note that

depending on the language of

a UR denial, based on an

MPN issue may be a waiver

of an MPN defense

depending on how worded ,

who the UR is addressed to,

and where on the document

does it state MPN Provider.

10. Transitional arrow to

next step

11. Defective URs,

normally means not all

medical records were not

considered, some insurance

companies incorrectly state

in a UR that "reviewed all

submitted records" or like

language, this is incorrect,

must list each and every

medical record by name

reviewed, therefore if not

considered defective,

however a defective UR does

not give way to a allowable

lien but must be used if an

IMR upholds a UR denial

and the Provider knows all

medical were not attached,

which is the number one

reason why IMRs uphold UR

denials, lack of

documentation. It is also

important to note that proper

documentation, even though

authorized services can effect

payment issues when it

comes to billing. This is a

fault in the industry by those

who take short cuts, they

believe they game the

system by a short cut only to

find the short cut cost them

payments when that process

is approached, this is more

noticeable in medical-legal

issues, where one gets over

the request by a party but

does not see it all the way

through , so a $10,000.00

payable bill then becomes a

$1,000.00 settlement, very

common.

12. Sends to Utilization

Review (UR Process), the

insurance UR use MTUS,

unless the Provider in

medical documentation

gives reason to expand

treatment to EBM. One

reason that generic medical

reports have harmed injured

workers and Providers alike.

One can actually tell by a

format of medical report that

either a Provider

documented or not and

whether services requested

are documented without

even reading the report as

there a large part of

Providers use the same

generic reports.


to next step

14. If untimely can file a

lien for WCAB, the issue

here is that still even if

untimely the Provider has to

show services within EBM,

so getting it right at the start

would be the proper way and

not look for untimely URs.


to next step


to next step

17. Time Frames

1.Concurrent , Prospective

(5 days or less) 2.Expedite



span of 12 months or

change in documented

medical condition: This

one of the most

important laws

regarding the IMR

process, but for different

reason than most think.

Example: I request a

epidural injection, it

comes back denied

because no MRI, I do an

MRI and can now

resubmit another RFA

immediately, for an

epidural injection as it is

a change in medical

facts affecting the UR

denial.Why Providers

do not apply is for the

simple reasons, maybe a

UR denial will ot say no

MRI but the IMR

upholding will, but that

takes too long and the

Provider already did the

injection before the MRI

decision. for a Provider

to use the above law

they have to understand

EBM, so they know

what is missing even

when not clearly stated

in the UR denials or

waiting for the MRI. Or

say a Provider request

12 physical medicine on

first vist denied because

exceeds number. the

Provider can immediate

for a RFA for 6 as

required for trial to

show objective

functional improvement

(is not a statement but

must show facts, as to

what improvements) ,

not same treatment.

However, one has to

understand EBM to

apply this law, as abuse

of it without a valid

cause will get a Provider

kicked off any MPN.

Example:The criteria for

the use of epidural

steroid injections are as

follows:

1) Radiculopathy must

be documented by

physical examination

and corroborated by

imaging studies and/or

electrodiagnostic

testing.

2) Initially unresponsive

to conservative

treatment (exercises,

physical methods,

NSAIDs and muscle

relaxants).

3) Injections should be

performed using

fluoroscopy (live x-ray)

for guidance.

4) If used for diagnostic

purposes, a maximum of

two injections should be

performed. A second

block is not

recommended if there is

inadequate response to

the first block.

Diagnostic blocks

should be at an interval

of at least one to two

weeks between

injections.

5) No more than two

nerve root levels should

be injected using

transforaminal blocks.

6) No more than one

interlaminar level

should be injected at

one session.

7) In the therapeutic

phase, repeat blocks

should be based on

continued objective

documented pain and

functional improvement,

including at least 50%

pain relief with

associated reduction of

medication use for six to

eight weeks, with a

general recommendation

of no more than 4

blocks per region per

year.

Elements:

• unresponsiveness

to

conservative treatment.

• imaging studies

• clear clinical signs

of radiculopathy and

non-corroborative

findings on imaging,


to next step

28. WCAB Disputed

Liability Process (Lien

Process) Although

most see the lien

process as simple,

based on how the IBR

and IMR process is

supposed to interact

with it is anything but

simple, add to that SB

1160. Lien Process is

supposed to be limited t

contested liability

issues, including

untimely URs and

untimely response to

second review, more

info is needed to truly

understand that

statement. " Contested

Liability Issues", is a

term born under SB 863.

which means denied

claim or any reason if

proven true the Provider

would be entitled to no

payments, however that

does not include failure

to comply with the time

requirement of IMRs

and IBRs, liens are

expressly prohibited if

the only issue is the

IMR or IBR process,

now enforceable

without hearings by

WCAB Judges or

Petition. Therefore, the

main goal of some

Providers who

disregarded the IMR

and IBR process and

filed liens have to use

the laws to pull those

claim back into either

the IMR or IBR process

before they are

dismissed.

29. Will only hear

denied cases, contested

liability issues ,

untimely UR,

Authorization process

and or Defective or

untimely payment , 2nd

review process /

Appeals from IBR or

IMR decisions and

Non-IBR Medical

Legal Disputes –

Including enforcement

of IBR decisions and or

penalties and interest.

Rushing to the WCAB

on filing a lien is

generally not the best

move for Providers,

they have to understand

the IBR and IMR

process and stay in

those 2 processes.


to next step


to next step

32. 2013 Files Lien 3

years from last date of

Service liens filed prior

to July 1, 2013 and after

January 01, 2013, prior

is based on old lien



laws--- for dates of services

after July 1 2013 18 months

to file lien from last date of

service Lien filing fee of

$150 for liens filed on or

after January 01, 2013 –

There are several

complications regarding

liens, first when are liens

not required: treatment for

future medicals, medical-

legal, if closing documents

addresses the medical bills

in question, and depending

on wording if the closing

documents holds the

applicant harmless for all

medicals. With SB 1160 we

are seeing that a lien can be

dismissed without a

hearing, if subject to IBR or

IMR or lack of

documentation showing

treatment outside an MPN

is warranted ( little more to

it but it will be discussed

later on). Presently

Providers have to look at

liens as a discount for

medical services provided,

as IBRs if subject too or

IMRs if subject too give

greater results than

settlements via liens.

Recently there have been

several panel decisions

discussing what happens

when the 3 year travels to

the 18 months of last date

of services, holding the 18

month applies thereby

holding that the Provider

forfeits the 3 years. Now

some will state they are not

collecting on the dates of

services that travel to the 18

months, this is invalid,

Providers do not get to

choose what last date of

services they can apply. In

addition, last date of service

applies to continual medical

treatment without

interpretation, meaning

testing is not continual

medical treatment even if a

second one is done 6

months apart. In 2017, both

the defense and Providers

should use Petitions to

resolve liens prior to

hearings as the issue are too

many and too complex to

leave to oral representation

alone, thus will happen

regardless of parties

willingness or not, as that is

the bases of SB 1160.

33. Medical Legal If Non-

IBR by petition no lien or

lien required if procedures

followed -- like the IBR

and the IMR process the

expediency to resolve

issues without liens, the

medical-legal process was

enacted. However, even

though the "Petition for

Non-IBR Medical-Legal"

has it purpose, some judges

have dropped the ball and

will push the medical-legal

to lien hearings defeating

the purpose to have the

issue resolved immediately.

Now for medical-legals,

IBRs give the better

decisions than the WCAB

which will discussed under

the IBR process.


next step

35. To get lien filing fees

fee must send offer 30 days

prior to filing, win at

hearing for an amount

equal to or greater than the

offer

36. Court order resolving

disputed liability issue may

have to go back to IMR or

IBR process where left off

with time limits


next step

38. Requires a retrospective

review 30 days to

complete if services already

provided review by UR. If

services not provided RFA-

- this where the IMR

process to to restart - or

start anew after deferred

based on a contested

liability issue.

39. UR has a life span of 12

months or change in

documented medical

condition

40-43. Is the process of

going through the IMR

process after a denied

injury and or contested

liability issue is resolved

44. Independent Bill

Reviewer (IBR) Process

the IBR process including

billing and second bill

review is the most

complex process of all

processes because it

touches every possible

issue regarding all issues

that effect Providers and

even case in chief issues.

This is where Providers

lose most of their monies,

in not understanding 0

pays, medical-legals,

objections, MPNs and

how it relates to

authorization, and what

EORs are actually stating

- this becomes more

crucial under SB 1160 to

master the IBR Process

more than any other.

For the defense under SB

1160 even prior, when

settling the case in chief,

at that time the defense

can request petitions for

dismissal for all service

that are subject to the

IMR or IBR and a Notice

to Dismiss can be issued

for liens filed, allowing

adjusters to close files

sooner. For Providers if they

understand IBR decisions

with relation to IMR

decisions Providers can see

a substantial increase in

monies and services, but

they have to break away

from the idea that they

understand payments or

medical necessity without

the add knowledge of these

IMR and IBR decisions.

This appears the hardest

concept for most in the

industry to get a hold of.

Example would be FCE, I

can show a Provider 50

IMR decisions on

authorization for an FCE,

and show them 20 IBR

decisions that state to be

paid at billed charges, and

still most cannot put it into

play because it does not fit

into what years of

experience or what they

learn at lectures, IBR and

IMRs are new and very

different then what

happened for years, this

concept is a major problem

for most Providers. So

simple, yet so hard to get it

through a block wall of

what most perceive what

they believe they think they

know.

45. Provider has 90 days to

seek second review if only

issue is reasonable



reimbursement-(date of

proof of service or date of

proof of receipt or if no

proof of services or receipt

5 additional days from post

mark). Now a second bill

review request is only

mandatory if the only issue

is the amount of payment of

a fee schedule adopted by

the administrative director

or payments under a PPO

contract and or contract for

services. This is collected

by two separate sections

regarding the IBR process

in which states may request

then another states

"If the only dispute is the

amount of payment and the

provider does not request a

second review within the

timeframes set forth in

subdivision (b), the bill

shall be deemed satisfied

and neither the claims

administrator nor the

employee shall be liable for

any further payment"

Now the amount of

payment issue may mislead

some believing that at least

something must be paid to

make it a dispute of

payment, this is a

misguided mistake and a

costly one, as most issues

of 0 pay in admitted injury

cases are subject to the

mandatory second review,

some not, but because of its

lack of use some of these

issue have not been

developed and in fact some

have developed incorrectly.

In addition some of the

regulations regarding

second review does defies

logic, but never-the less it

is the law, example would

be the difference between a

incomplete bill which is

subject to second review as

opposed to a rejected bill

where we have to travel to

the billing laws to find the

difference. That aside there

are many benefits for

Providers to master the IBR

process, but few use it and

accounts for the simplest of

monies lost.

The additional issue with

requests for second bill

review, is that if a Provider

does not use the required

form adopted by the DWC,

the insurance does not have

to respond timely nor pay

timely, therefore all those

who did not use the proper

form and are yelling

untimely response and filed

a lien that defense is not

valid and such liens are

subject to dismissal by law

after notice.

A claims administrator may

respond to a request for

second bill review that does

not comply with the

requirements of subdivision

(d). Any response to such a

request is not subject to the

requirements of

subdivisions (g) and (h) of

this section.

In the statement of reason

for the IBR regulations, it is

stated that the second bill

review request was for the

purpose of limiting appeals

to one, so that an adjuster is

not overwhelmed with

many appeals on the same

issue, however, some MPN

contracts do allow an

addition informal appeal

before jumping into the

formal IBR process, one

would have to read such

internal policy as it is not

common to all insurance

companies.

Second bill review requests

are not an end to the

process but the start, if

additional monies not paid

or not paid to fee schedule,

by report or contract, then

an IBR has to be done in 30

days or the insurance can

close their file and no

additional monies owed, a

waiver.


next step

47. By WCAB adopted

rules of Oct 2013 failure to

respond to second review

within 14 days now a lien

issue and provider gets paid

fee schedule, this is the way

that the regulation was

written at the start of 2013,

"paid fee schedule then in

effect for that date of

service" which made little

sense as it give the

insurance no incentive to

respond timely or not at all.

Therefore, mid 2013 they

took the wording pay fee

schedule and made it a

default law against the

insurance for not respond

or responding untimely,

only 1 of 2 defaults outside

of IBR decisions as to

objections and document

submitted, in SB 863

regulations, against

insurance that increase

penalties for not

complying, the other being

partial payment being made

within 30 days of a RFA

operates as an authorization

of services of that RFA.

However to benefit from

this law proper form and

information must be in that

request for second review,

of which a great many of

Providers did not do until

the start of 2016, some still

not using proper form or

information. The problem

with the default as clearly

stated in the laws, is that it

had not been developed and

the question as to what

forum to use to get the

default, as it has not been

used nor known by most,

which kind of sums up the

entire system under SB

863, most do not know

what they do not know, and

defaulting to what they do

known and missing benefits

under the laws, both by the

defense and Providers

alike.

There are several ways in

which the time limits can

be restarted of the request

for second review, however

these methods are not

written in the laws but

developed by a series of

IBR decisions, therefore,

violating the 90 day rule

may or may not close the

door to start anew the 90

day time limit, important to

know these laws developed

by IBR decisions.




next step


next step


next step

51. After and only after

second review Provider has

30 days to seek IBR by

form failure to do so

operates as a default and

insurance not obligated to

pay anymore.

52. Request for second

review by form after initial

review of medical bill 90

days or no further recourse

-- failure to comply with

the time requirements

operates as a waiver

communicating in a sense

acceptance what was paid.

A large number of

Providers or Collection

Companies failed to take

these time requirement

seriously, now in 2017 all

those defaults can be

dismissed without a

hearing.

53. Cannot file a lien if

only issue subject to IBR

unless untimely , initially

sanction were to be

imposed for filing a lien

could still be but now a

Judge can dismiss or notice

to dismiss without a formal

hearing or setting for

hearing, even at the case

and chief hearing.


next step

55. Fee for IBR $195.00 if

the Provider wins an IBR

decision an order issues for

reimbursement of $195.00

(in addition to money

owed)

56. Can consolidate IBR 3

different fact patterns to

consolidate different dates

of services, different

injured workers and more

Before we finish, it is

important to note that the

above and what is to

follow, seems complicated,

this is true for the simple

reason that at the start of

2013 most did not apply SB

863 in total, Providers and

insurance alike , so now we

have 4 years of decisions ,

IBR and IMR and WCAB,

and Medical-legal, that are

built on, added to the

foundation created by SB

863. Therefore, now, four

years are added to what was

simple at the start 2013 and

if a foundation was not had

at the start of 2013, it now

appears more complex than

it is.

The progression that

Provider issues from 2013

to 2017 is as follows: at the

start of 2013 a billing code

or a service or treatment

could have been written on

half a page. Now based on

IBR, IMR, Medical-Legal

decisions and WCAB

decisions , each billing

code a 20-30 page book can

be written based on

objections and payment and

common mistakes. Based

on IMR decisions for a

service, product or

treatment a 30-40 page

book could be written on

each one to show when

applies and as to medical-

legal now in 2017 a 300

page book can be written

based on IBR and WCAB

decisions, knowledge in

2017 either makes success

or failure.

It is not that it cannot be

made simple, it is just an

aversion by most to keep up

with the laws; examples: I

know of adjusters who pay

out millions in settlements

for certain Providers and

services, even though a law

interpreted in 2015 says

they do not have to even

stating the law incorrectly,

nothing to do with SB 863 ,

or I know of Providers who

lose thousands each day for

failure to venture into what

they do not know, or

medical groups losing 10 to

a $100,000.00 a day as they

stubborn refuse to grasp a

simple and more productive

method based on IBR and

IMR decisions and

medical-legal IR decisions

57. Court order resolving

disputed liability issue may

have to go back to IMR or

IBR or 2nd bill review

process where left off with

time limits- This law is



mentioned 3 times under

SB 863, once for 2nd Bill

review request, once for

IBR request and once

adjuster to do a 30 day

retrospective review. What

this means is depending on

wording and action an

adjuster can pay 0 on a

case denied and later

admitted or a Provider can

get its asserted billed

charges in a case denied

later admitted, a odd

succession of laws that

touch the action of all

parties to come up with

either results, that has not

been applied for 4 years

except one or two adjusters

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