Billing Disputes Post SB863 / IBR Adventures

Prior to Senate Bill 863 Medical Providers could file liens on unresolved billing disputes. If the carrier’s bill review company did not pay appropriately most providers would send a letter to the bill review company or the adjuster making a case as to why they thought they should be paid differently. If that approach was not successful, most providers would just file a lien with the WCAB. SB863 promulgated new rules regarding billing disputes and lien filing. A provider can no longer file a lien if the issue is the amount paid by the carrier. The exact wording of the regulations regarding this is as follows:

“If the provider disputes the amount of payment made by the claims administrator on a bill for medical treatment services rendered on or after January 1, 2013…”

Unfortunately this statement leaves the provider wondering about the codes that were disallowed altogether. Are those codes also subject to this process or do those services warrant a lien?

For instance, let’s say the provider is authorized to do a consultation.

• Clear written authorization is given for a consultation.
• The provider sees the patient and reviews records, does some minimal testing and completes a consultation report.
• The billing is submitted with the report for all the above services.

The bill review company allows payment for the face-to-face time and record review but does not allow for the testing or the report. Is this an issue for IBR?

The Official Medical Fee Schedule clearly indicates that consultation reports are payable, but the issue here is not just the amount paid, it is that they did not allow payment for the report. The same goes for testing, most carriers/bill review companies understand that some testing is required in order to render a medical opinion and most pay for testing without specific written authorization. Sometimes, bill review does not allow payment for record review, is this also an issue for IBR? These are my questions at this time.

I have filed 3 IBR’s so far. I filed the first one in June and just now received a response saying it did not meet the established criteria for consolidation. The learning curve is steep. We had one provider, one patient, one claim, but there were 3 codes being disputed and one code was on a different date. The letter I received from DWC Medical Unit did not indicate whether or not the provider would be reimbursed the filing fee of $335.00 in part or in whole nor did it indicate that we may now disaggregate the IBR and submit the dates separately by paying the filing fee twice. Are we time barred now since we only have 30 days from the second appeal EOB?

Hopefully the DWC can get these issues resolved and send clearer communication.

Stay tuned for more IBR adventures.