In decades past, courts had more discretion over lien disputes and often allowed lien claimants substantial leeway when it came to procedural and evidentiary issues. In fact, it was common for defense attorneys to have to remind the parties that it is the lien claimants’ (and not the defendants’) burden to prove up the lien.

Kelly A. Curtius

Fortunately, the workers’ compensation system has since seen dramatic changes in regulations governing lien claimants’ billing, and useful defenses have emerged.

One such defense, outlined in LC 4603.2(e) and CCR 9792.5.5, is the second review procedure. It states that a provider who disputes the amount of payment made by the claims administrator on a bill for medical treatment, services or goods rendered on or after Jan. 1, 2013, must request that the claims administrator conduct a second review of the bill.

The request for a second bill review must be made within 90 days of either:

• Service of an explanation of review (“EOR”).
• Within 90 days of an order of the Workers' Compensation Appeals Board resolving a threshold issue stated in the EOR.

The request for a second bill review submitted by the provider must also include:

• The original dates of service and the same itemized services rendered as the original bill (no new dates of service or additional billing codes may be included).
• The date of the explanation of review and its claim number or other identifying number.
• The item and amount in dispute.
• The additional payment requested and reason for it.
• The additional information provided in response to a request in the first explanation of review or any other additional information provided in support of the additional payment requested.

In cases where the only dispute is the amount of payment, a provider must request a second bill review within 90 days. If it fails to do that, the bill is deemed satisfied and the employer is not liable for any further payment.

For example, in the published decision of Meadowbrook Insurance Co. v. WCAB, Meadowbrook authorized interpreting services on two accepted claims. The interpreting company billed Meadowbrook, which issued EOBs that refused payment. In response, the interpreting company filed a lien to seek reimbursement, and the case headed to trial.

Ultimately, the 3rd District Court of Appeal held that because an interpreter for medical treatment failed to request a second review of its payment pursuant to LC 4603.2(e), its bill was deemed satisfied and the defendant was not liable for further payment. While there were other arguments in the case about whether an interpreter fee schedule existed at the time (the 3rd DCA ruled that one did), the arguments regarding the second bill review played an important role in the decision.

Takeaways

It’s important to remember that the second bill review rule applies only in situations where the sole dispute is the amount of payment. If there is a threshold issue, the obligation to request a second review is deferred until that issue is resolved at the WCAB.

Threshold issues include denial of injury, a contested body part or alleged improper treatment outside a proper network.

As noted above, the statute requires a request for a second review to be made within 90 days of an appeals board order resolving a threshold issue, and it may be that failure to do so will bar further recovery. But this is not stated explicitly in LC 4603.2(e)(2) or the regulations.

So, before you engage in settlement negotiations with lien claimants involving disputed payment amounts, make sure to confirm whether they timely and properly requested a second bill review. If they failed to do so, they are out of luck, as their bill is deemed satisfied.

Kelly A. Curtius is an associate attorney at Bradford and Barthel’s Los Angeles office. This entry from Bradford & Barthel's blog appears with permission.