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Carrico: Understanding IBR Can Resolve Valuation Disputes

  • State: California
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Understanding how to use independent bill review is a key tool in lien litigation that can help resolve balance valuation disputes that used to extend the life of cases for years.

Keane A. Carrico

Keane A. Carrico

Liens can be potentially high exposure, and the law for liens tends to largely go undiscussed and unstudied. However, knowing how to defend lien claims is a great way to limit liability for an insurance carrier, particularly when the claims are accepted.

I will cover the issue of IBR, which is a cornerstone of determining medical treatment billing for accepted claims.

IBR process

Medical treatment billing disputes are resolved through the IBR process. A medical provider who disagrees with the amount paid by a claims administrator on a properly documented bill may apply for IBR.

For IBR to apply, medical services must have started on or after Jan. 1, 2013, with a fee determined by a fee schedule established by the Division of Workers’ Compensation. However, if a claims administrator has contested liability for the bill for any issue other than the fee, then that issue must be resolved before the matter can go to IBR.

Required documents

Providers must attach the following, pursuant to LC 4603.2(b)(1):

  • A request for payment with an itemization of services provided and the charge for each.
  • Copies of reports showing the services performed.
  • The prescription or referral from the primary treating physician if the services were performed by someone other than the primary treating physician.
  • Evidence of authorization for the services received (requests for authorizations that went unanswered or utilization reviews that certified the services).

Time limit to submit bills

For services on or after Jan. 1, 2017, the request for payment with an itemization of services provided and the charge for each must be submitted to the employer within 12 months of services or within 12 months of discharge for inpatient facility services. This is different from the statute of limitations to file a lien, which is 18 months after the last service was provided.

Explanation of review

An explanation of review is a key step before going to IBR. Defendants send EORs to the provider, “upon the payment, adjustment or denial of a complete or incomplete itemization of medical services.”

See below for more details on what the rules and regulations require from EORs.

Time limits for objection to payment

An employer may decide to pay or reject the bill or pay part and object to the remainder.

If some or all of the itemized bill is contested, denied or considered incomplete, then the physician must be notified in the EOR within 30 days of receipt of a paper itemization by the employer.

An objection to a paper itemization is timely if sent by first class mail, personally delivered or sent by fax on or before the 30th day after receipt. If an electronic bill is received, then the objection must issue within 15 days working days of electronic receipt.

The employer must pay any uncontested amount within the appropriate period:

  • If a portion of the nonelectronic bill is uncontested, then it must be paid within 45 days.
  • If an electronic bill is uncontested, then it must be paid within 15 working days.

Contents of explanation of review

Labor Code 4603.3(a) requires that on payment, adjustment or denial of a complete or incomplete itemization of medical services, an employer must provide an EOR in the manner prescribed by the administrative director that includes:

  • A statement of the items or procedures billed and the amounts requested by the provider.
  • The amount paid.
  • The basis for any adjustment, change or denial of the time or procedure billed.
  • The additional information required to make a decision for an incomplete itemization.
  • The reason for the denial of payment if it’s not a fee dispute.
  • Information on whom to contact on behalf of the employer if a dispute arises over the payment of the billing.
  • The time limit to raise any objection regarding the items or procedures paid or disputed and how to obtain an independent review of the medical bill.

Failure to issue EOR

The IBR process requires the employer to provide an EOR when paying less than the amount requested by the provider. The IBR process does not apply to disputes in which an employer fails to provide an EOR. Also, if the employer fails to provide a required EOR, then the provider is not required to file a request for IBR, and the Workers' Compensation Appeals Board will have jurisdiction over the dispute.

Request for second bill review

Once a valid EOR is issued, a medical provider must request a second bill review within 90 days. This request must include:

  • The date of the EOR.
  • The item and amount in dispute.
  • The additional payment requested and why.
  • The additional information requested.

Failure to request second bill review

“If the only dispute is the amount of the payment and the provider does not request a second review within 90 days, the bill shall be deemed satisfied and neither the employer nor the employee shall be liable for any further payment,” according to statute.

If there is a threshold issue instead of an issue regarding the amount of payment, then the obligation to request a second review is deferred until that issue is resolved at the WCAB (such as alleged improper treatment outside a proper medical provider network).

Second bill review

The employer must respond within 14 days of a request for SBR.

The response is a final written determination on all items or amounts in dispute. The determination must contain all of the information required in an EOR. Any additional amounts to be paid based on the SBR must be made within 21 days of receipt of the request for a second review.

IBR

If the provider still contests the amount paid after receipt of the SBR, he must request an IBR under LC 4603.6. An independent bill review is an order of the administrative director. Failure to do so timely generally results in the inability to pursue the bill any further.

The provider must file the administrative director form IBR-1, the original bill, supporting documentation, EOR, the request for second bill review and the second bill review.

An independent bill reviewer will be assigned within 30 days of request. Any documents requested by the reviewer must be submitted within 10 days. The provider pays the $355 IBR fee. If the review finds that additional payment is owed, then the provider gets the amount owed and fees reimbursed.

Within 60 days of receipt of assignment, the independent bill reviewer shall make a written determination of the amounts to be paid, if any, and the reasoning.

Keane A. Carrico is an associate attorney at Bradford & Barthel’s Anaheim office. This entry from Bradford & Barthel's blog appears with permission.

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