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PUBLICATIONS, EDUCATION AND INFORMATION FOR TREATMENT AND
COLLECTIONS DISPUTES
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California Workers' Comp
URINE DRUG SCREEN    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
ISSUE IN DISPUTE Provider is dissatisfied with denial of codes 72070 and 72110
ISSUE IN DISPUTE The reimbursement of CPT 17999 for date of service
1/31/2014
ISSUE IN DISPUTE:  Provider is dissatisfied with down -coding of 99204 to 99203
and reimbursement for multiple injured workers with separate dates of service.
ISSUE IN DISPUTE : Provider seeking remuneration for the following
medications and
compound medications: NDC 38779187105, NDC 38779273904 , NDC
38779039503,
NDC 38779038803, NDC 38779008202 , NDC 00591367105, NDC
76218121901,
NDC53746011005 and NDC 60505006601 dispensed to Injured Worker on
05/05/2014
ISSUE IN DISPUTE: Provider seeking remuneration for 97530-59 x 4 Units
Physical
Medicine services performed on 02/26/2014–03/05/2014
ISSUE IN DISPUTE :Provider seeking additional remuneration for WC004
PR4 report
up to 15 pages.Upon second bill review, no additional payment for WC004
was issued
ISSUE IN DISPUTE: Provider seeking full remuneration for 82145,
80154,82520 ,83925,83925-59,82145-59 Laboratory services performed on
04/02/2014
ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of DRG 454,
Inpatient
Services.
ISSUE IN DISPUTE: Provide r seeking remuneration for Lab Services CPT
Codes, 82205, 82520, 83840, 83992 , 83992, 83925, 83925 - 59, 82145 and
82055 (G4034) for date of service 01/28/2014
CT SCAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
2015 Book on Authorization, Utilization Review With 1000 IMR Decisions to Show Why
Treatment is not Being Authorized. Not only did the formalities of the WCAB and the IBR
process change but also the detail requirements in the request for authorization and to get UR
reversal by IMRs. A missed word and a left out explanation, a lack of documents, changes if the
treatment is authorized or if reversed and certified by IMR
Also receive 1500 IBR Decisions summarized
and indexed
EMG/NCS   = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
SLEEP EVALUATION WITH TESTING= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
8 WEEK 24 LESSON COURSE  IN WORK COMP TREATMENT AND
COLLECTIONS for $325.00 (INDIVIDUAL OR ENTIRE STAFF)
INTRATHECAL PUMP = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
8 WEEK 24 LESSON COURSE  IN WORK COMP
TREATMENT AND COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE STAFF)
MANIPULATION UNDER ANESTHESIA = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
6 Month  24 LESSON
COURSE  IN WORK COMP
TREATMENT AND
COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE
STAFF)
ISSUE IN DISPUTE: Provider seeking full remuneration for  99499 Unlisted Evaluation
and Management services representing Functional Restoration Program for service dates
04/07/2014 04/11/2014.
ISSUE IN DISPUTE: Provider questioning Claims Administrator’s re-coding of 99214
Evaluation and Management service provided to Injured Worker on 01/29/214 and $0.00
reimbursement for 99070 -NDC#68453095010 submitted charge.
AMBIEN = Guidelines = Elements Required in Documentation =Common Errors= Authorized
ANAPROX  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
ATIVAN = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CAPSAICIN 0.025%, FLURBIPROFEN 20%, TRAMADOL 10%,MENTHOL 2%, CAMPHOR 2%=
Guidelines = Elements Required in Documentation =Common Errors= Authorized
CARAFATE = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CARISOPRODOL = Guidelines = Elements Required in Documentation =Common Errors= Authorized
PSYCHIATRY VISITS   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CELEBREX= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CLONAZEPAM  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
COLACE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
PSYCHOTHERAPY      = Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
COMPOUND CREAM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
SKILLED NURSING  = Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
COMPOUND GABAPENTIN POWDER= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
CYCLOBENZAPRINE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CYMBALTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
TRIGGER POINT AND TENDER SPOT INJECTIONS = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
DENDRACIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LUMBAR FUSION W/ INSTRUMENTATION, USE
AUTOGRAFT AND/OR ALLOGRAFT:= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DIAZEPAM (VALIUM)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICLOFENAC  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICOPANOL (DIPHENHYDRAMINE)= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
DICYCLOMINE HCL 2= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DILAUDID= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CARDIAC CLEARANCE   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CARDIOLOGY CONSULT = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
CONSULT WITH PAIN MANAGEMENT = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
EKG = Guidelines = Elements Required in Documentation
=Common Errors= Authorized  EKG
ELECTROENCEPHALOGRAPHY (EEG) = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
ELECTROMYOGRAM    = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
GROUP THERAPY = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
HOME HEALTH CARE = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
NEUROLOGICAL CONSULTATION   = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
NEUROSTIMULATION THERAPY = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DME Varies  = Guidelines = Elements Required in
Documentation =Common Errors= Authorized  EKG
REFERRAL TO NEUROSURGEON = Guidelines =
Elements Required in Documentation =Common
Errors= Authorized
NUCLEAR STRESS TEST = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
OCCUPATIONAL THERAPY= Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
PAIN MANAGEMENT    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PLATELET RICH PLASMA INJECTION  = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PNEUMATIC INTERMITTENT COMPRESSION   =
Guidelines = Elements Required in Documentation =Common
Errors= Authorized
INTERMITTENT COMPRESSION DEVICE= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PRE-OP TESTING = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHE TREATMENT= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHIATRIC MEDICATIONS MANAGEMENT   = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
PSYCHOLOGICAL EVALUATION = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
PSYCHOPHARMACOLOGY MANAGEMENT    =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
SPINAL SURGICAL CONSULTATION= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DEBRIDEMENT OF THE RIGHT SHOULDER =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
SHOULDER OPEN ROTATOR CUFF REPAIR = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
KNEE ARTHROSCOPY= Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
SHOULDER ARTHROSCOPY = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
WORK HARDENING VISITS = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
DUEXIS= Guidelines = Elements Required in Documentation =Common Errors= Authorized
EFFEXOR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FENTANYL= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FEXMID = Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLECTOR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLEXIRIL= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLURBIPROFEN CREAM,= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLURIFLEX (FLURBIPROFEN/CYCLOBENZAPRINE 15/10 %) CREAM 1= Guidelines = Elements
Required in Documentation =Common Errors= Authorized
GABAPENTIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
HYDROCODONE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
IBUPR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
KETOPROFEN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
KLONOPIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LIDOCAINE PAD= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LIDODERM PATCH= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LINZESS= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LORTAB ELIXIR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LYRICA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MELOXICAM (MOBIC)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
METHODERM OINTMENT= Guidelines = Elements Required in Documentation =Common Errors=
Authorized
MENTHODERM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MORPHINE SULFATE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MS CONTIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NABUMETONE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NAPROXEN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NOCTURNAL OBSTRUCTIVE AIRWAY ORAL APPLIANCE / DECAY OR FRACTURED TEETH=
Guidelines = Elements Required in Documentation =Common Errors= Authorized
NORCO= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NUCYNTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
OMEPRAZOLE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
ONDANSETRON ODT = Guidelines = Elements Required in Documentation =Common Errors= Authorized
From Program: Second Review and IBR Response:    63047-62-22 &
63048-62-22 x2 units
Additional remuneration for Co-Surgeon Services
relating to 63047-62-22 Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral with decompression of spinal cord, cauda equina
and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar & add -on code 63048-62-22 Laminectomy, facetectomy and
foraminotomy (unilateral or bilateral with decompression of spinal cord,
cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]),
single vertebral segment; each additional segment, cervical, thoracic, or
lumbar (list separately in addition to code for primary procedure)x 2 Units,
performed on 08/29/2014
From Program: Second Review and IBR Response:    IBR unable to
calculate a rate of reimbursement for 4 ounces of Keratek Gel as the
NDC# provided appears to be invalid and the submitted invoice does not
indicate a per bottle weight of the ’24 bottles’ reflected. 99070  NDC#
54162054004 QTY 113
From Program 2015 Papers Articles: Adjusters-Liens, Who are They, What Did They Do with The
Old Adjusters
From Program: Second Review and IBR Response:    As a contractual
agreement between the Provider and the Claims Administrator does not
exist; OMFS will be utilized to calculate reimbursement.•Based on
information reviewed, additional reimbursement for codes 99213 and
WC002 is warranted
From Program: Second Review and IBR Response:    96101 -Psychological
testing
(includes psychodiagnostic assessment of emotionality,
intellectual abilities, personality and psychopathology, eg, MMPI,
Rorschach, WAIS), per hour of the psychologist's or physician's time, both
face-to-face time administering Tests to the patient and time interpreting
these test results and preparing the report
From Program: Second Review and IBR Response:    J2278-KD NDC
418860072010 documentation indicates Prialt 100 mcg/1 ml x 6 viles of
single dose ampule administered to Intrathecal Pain Pump $3,960.00
2015 Posted Articles
From Program 2015 Papers Articles:WC:Collection Paper vs. Providers'
Receivables 10 Cents on The Dollar?
From Program 2015 Papers Articles: We Fooled Providers for So Long,
They Now Turn a Deaf Ear to Us--Help.
From Program 2015 Papers Articles: (PBM), DISCOUNTED PAYMENTS FOR PHARMACY,
BIGGEST FRAUD SINCE PPOS OR ?
From Program 2015 Papers Articles: WC: Providers Have Always Been
Underpaid, Just No One Ever Told Them
From Program 2015 Papers Articles: determination of Medical-Legal Dispute, Interpreter, Copy Service,
From Program 2015 Papers Articles: WC: Receivables= Strategic,
Tactical,  Operational & Contingency Planning
From Program 2015 Papers Articles: WC: Reading Laws Incorrectly,
Putting Receivables on a Path of Default
From Program 2015 Papers Articles: Chiropractic Beyond 24 w/o Surgery
/ When Necessary for Wrist and Hand
From Program 2015 Papers Articles: WC: Why Some Providers are
Cheating Themselves out of Payments Due
From Program 2015 Papers Articles :WC: Frauds That Survived SB 863, PPOs, MPNs,
Prescription Drug Cards
From Program 2015 Papers Articles: WC: The Power Of Requests for 2nd
Bill Review and Notice to File Lien
From Program 2015 Papers Articles: UR Certification, Same as Authorized,
PBM, MPN, PPO Denied Body Part?
From Program 2015 Papers Articles: The Day of a Work Comp Collector,
That What We Perceive No Longer True
From Program 2015 Papers Articles: Mythical Search For The Answer to
94% Authorized Treatment/ Services
From Program 2015 Papers Articles: WC: Treatment / Collection Disputes
The One Thing That Can No Longer be Glossed Over
Program: 2015 Education Video Lectures
Program: Objections and Responses As Determined by decisions : ML 104:
Claims Administrator reimbursed $2636.72 indicating on the Explanation of
Review “In accordance with the California Official Medical Fee Schedule,
Section 9789.15.1, this service was reduced due to the non-physician
practitioner (NPP) payment methodology. (MNPR)  --incorrect
Program: Objections and Responses As Determined by decisions :     claims
administrator denied code indicating on the Explanation of Review “Service/item
included in the value of other services per CCI edits. Related service could be on
separate bill.” incorrect-    Provider billed code 96101-59 along with 99205.
Program: Objections and Responses As Determined by decisions :Claims
administrator reimbursed $59.12 indicating on the Explanation of Review “The
number of units billed for this procedure code exceeds the reasonable number
usually provided in a given setting as defined within the Medically Unlikely
Edits (MUEs) which is published and maintained by the Centers for Medicare
and Medicaid Services” This denial is incorrect as these are lab charges not
physician charges.
Program: Objections and Responses As Determined by decisions : Claims
Administrator reimbursed $113.34 of billed amount $1396.80 indicating on the
Explanation of Review “Charge for pharmaceuticals exceed the fees established by
the fee schedule/UCR rates” Compound Medication Claim Administrator Incorrect
Program: Objections and Responses As Determined by decisions : Provider
seeking remuneration for the following Ambulatory Services performed on
11/03/2014: 64635-SG $860.00; 64635 -SG-50 $430.00;64636-SG $568.00; &
64636-SG-50 $568.00. •Claims Administrator denial rational: “Reimbursement
for this service is not payable to Ambulatory Surgical Centers  --- Incorrect
Program: Objections and Responses As Determined by decisions :The Claims
Administrator did not reimburse the Provider based on the Multiple Endoscopy
guidelines as described in the OMFS Physician Fee Schedule Regulation effective
January 1, 2014. Therefore, reimbursement of code 29881 is warranted.  
Program: Objections and Responses As Determined by decisions :G0260-
LT  Provider billed the disputed CPT codes on a UB04, bill type 831 for date of
service 10/02/2014. •Claims Administrator reimbursement rational: “Service not
paid under outpatient facility fee schedule  - incorrect
Program: Objections and Responses As Determined by decisions : 95913
nerve conduction studies; 13 or more studies, performed on 9/26/2014. •Claims
Administrator denied the service with the following rational: “The documentation
does not support the level of service billed. Reimbursement was made for a code
that is supported by the Documentation  submitted with the billing .” Reimbursed
as 95912 Nerve conduction studies; 11-12 studies
Program: Objections and Responses As
Determined by decisions :
Claims administrator
down coded ML 104 to ML 102 indicating on the
Explanation of Review “Documentation doesn’t
support the level of services” and “Lower ML 104
to ML 102.
Program: Objections and Responses As Determined by decisions : Provider
seeking full remuneration for 99214 Evaluation and Management Services
performed on 10/27/2014.•Claims Administrator applied reimbursement relating to
CPT 99213 with the following rational: “The documentation doesn’t support the
level of service billed. Reimbursement was made for a code that is supported by
the description and documentation submitted with the billing
Program: Objections and Responses As Determined by decisions : 63012-59
and 63047-59 for date of service 4/7/2014.•Claims Administrator denied both
codes indicating on the Explanation of Review “National Correct Coding Initiative
Edit–either mutually exclusive of or integral to another service performed on the
same day”; “The benefit for this service is included in the payment/allowance for
another service/procedure that has already been adjudicated”and “No separate
payment was made because the value of the service is included within the value of
another service performed on the same day.”
Program: Objections and Responses As Determined by decisions :
Remuneration for Inpatient Hospital DRG 0470 for dates of service 09/14/2014
–09/20/2014.• Claims Administrator based reimbursement with the following
rational: “PPO Amount.”•Contractual agreement not available for IBR
Program: Objections and Responses As Determined by decisions :ISSUE
IN DISPUTE: Provider is dissatisfied with denial of code 90837 for multiple
dates of service. •Claims Administrator denied codes indicating on the
Explanation of Review “CPT code submitted is based on service time and
documentation does not support the time spent on this procedure.” • -
Psychotherapy, 60 minutes with patient and/or family member
Program: Objections and Responses As Determined by decisions :
Provider is billing their services as outpatient services in which the
outpatient ruling does not list long term care hospitals as being exempt
from the fee schedule. They are exempt from IPPS, but not
OPPS in which case the OPPS rules would still apply to this bill.
Additionally, the provider is within the PPO network and subject to
further reductions.”
Program: Objections and Responses As Determined by decisions
:ISSUE IN DISPUTE: Denial of CPT code 63650-59
Program: Objections and Responses As Determined by decisions :ISSUE
IN DISPUTE: Provider disputing reimbursement for ML104, 73110, 72110,
73562, 73030 and 72040 services performed on 03/27/2014. •Claims
Administrator ML104 reimbursement rational: “FCE Not Requested,” and
“Not Authorized.” •FCE “Functional Capacity
Program: Objections and Responses As Determined by decisions :
Denial of code 99199 Special Report.
Program: Objections and Responses As Determined by decisions :
Denial of ML 104-94 - $10,687.50 ordered paid
Program Files Medical Necessity RFA:  Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Left knee arthroscopy
with partial meniscectomy, possible chondroplasty and possible
removal of loose bodies: Overturned
Program Files Medical Necessity RFA: Lumbar ESI at L5-S1:
Overturned
Program Files Medical Necessity RFA: Computed
Tomography (CT) of the Cervical Spine: Overturned
Program Files Medical Necessity RFA: Physical Therapy (3x
week/6 weeks, 18 Total Visits: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychotropic therapy, once per week for one week: Overturned
Program Authorization UR Denials Overturned by IMR:
TWELVE (12) PHYSIOTHERAPY VISITS :Overturned
Program Authorization UR Denials Overturned by IMR: initial
Ortho Consult for Left Elbow and Left Wrist: Overturned
Program Authorization UR Denials Overturned by IMR: Pain
management consultation: Overturned
Program Authorization UR Denials Overturned by IMR:
Clonidine 0.1mg #90: Overturned
Program Authorization UR Denials Overturned by IMR:
MRI Arthrogram Right Ankle:Overturned
Program Authorization UR Denials Overturned by IMR: Pain
Management Consultation:Overturned
Program Authorization UR Denials Overturned by IMR:
POST-OP PHYSICAL THERAPY FOR THE RIGHT
SHOULDER 3 X 4:Overturned
Program Authorization UR Denials Overturned by IMR:
Follow-up internal medicine evaluation: Overturned
Program Authorization UR Denials Overturned by IMR
Neurosurgical consult: Overturned
Program Authorization UR Denials Overturned by IMR
Retrospective request for Norco 10/325 mg #60
DOS:1/24/14:Overturned
Program Authorization UR Denials Overturned by IMR: Right
Shoulder Arthroscopic Rotator Cuff Repair with Decompression:
Overturned
Program Authorization UR Denials Overturned by IMR:
Med panel to evaluate hepatic and renal function: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychological Evaluation: Overturned
Program Authorization UR Denials Overturned by IMR: Left
Knee Video Arthroscopy, Medial Meniscectomy : Overturned
Program: Objections and Responses As Determined by decisions : (E/M)
service by the same physician on the day of a procedure:  
New:

DRG 491 PPO Issue

Tuesday, June 30, 2015

7:31 PM

 

 

ANALYSIS AND FINDING  Based on review of the case file the following is noted:

·

ISSUE IN DISPUTE: Provider seeking full remuneration for Inpatient Hospital Services DRG 491

Back & Neck Proc.Exc. spinal fusion W/O CC/MCC performed 09/08/2014 -09/09/2014.

·

Claims Administrator reimbursement rational: “No further reimbursement was made as the maximum allowance has been reached for this admission. Labor Code 5307.1”·

§9789.21. (o) "Inpatient Hospital Fee Schedule maximum payment amount" is that amount determined by multiplying the DRG weight x hospital composite factor x 1.20 and by making any adjustments required in Section 9789.22 (G)(2).

·

DRG 491 is not listed in Section 9789.22 (G)(2) for additional fees.

·

Contractual Agreement Not Available for IBR. As such, 100% OMFS will be utilized to

calculate payment pursuant to §9789.21.The table below describes the pertinent claim line information

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_10-100/CB15-0000014.pdf>

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

DRG 491

$65,218.79

$1,425.00

$14,803.38

1

 

$14,239.99

Additional awarded $12,814.99

 

 

Machine generated alternative text: . DRG 491 is not listed in Section 9789.22 (G)(2) for additional fees.
. Contractual A2reement Not Available for IBR. As such. 100% OMFS will be utilized to
calculate payment pursuant to §9789.2 1.
The table below describes the pertinent claim line information.
DETER11EWAHON OF ISSUE IN DISPUTE: Reimbursement of code 29846
Date of Service: 09:082014 -O909.2014
In Patient Hospital _______ ____________
. Workers’
Service Provider Plan Dispute Un.ft Comp N t
Code Billed Allowed Amount S Allowed o es
Amt.
DRG 491 $65,218.79 $1,42500 $14,803.38 1 $14,239.99 ONffS — Reimbursed
Amount = S12,8 14.99
Due Provider.

 

 

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One place for all your notes and information

Simple Consultation (E&M)0 Paid Order 60 Days $805.32 no Lien Plus P&I

Wednesday, July 1, 2015

11:41 AM

 

 

Machine generated alternative text: DETERMINATION OF ISSUE IN DISPUTE: Reimbursement of codes 99205-25, 99354 &
96101-59 is recommended
Workers’ I
Comp ,
Notes
Allowed
DISPUTED SERVICE: Allow
__________ _________ _________ _________ _________ _________ _________ I reimbursement $237.67
DISPUTED SERVICE: Allow
reimbursement $114.35
DISPUTED SERVICE: Allow
reimbursement $453.30
Date of Service: 8.20.2014
Physician Services
Service
Code
Provider
Billed
99205
Plan Dispute
Allowed Amount
$275.00
$0.00
Units Multiple
Surgery
$275.00
1
96101-59
Amt.
N/A
99354
$125.00
$0.00
$125.00
1
N’A
$114.35
$500.00
$237.67
$0.00
$500.00
5
N’A
$453.30

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

99205

$275.00

$0.00

$275.00

1

 

$237.67

Award: $237.67

99354

$125.00

$0.00

$125.00

1

 

$114.35

Award: $114.35

96101

$500.00

$0.00

$500.00

5

 

$453.30

Award: 453.30

 

 

 

 

 

 

 

 

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted:

·ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 99205-25, 99354 & 96101-59

 

Claims Administrator denied codes indicating on the Explanation of Review “We cannot review this service without necessary documentation. Please resubmit with indicated documentation as soon as possible”

 

Provider states on the IBR application “A copy of the report was attached to the SBR which we sent on January 20, 2015 and again, bill review has denied it with the same explanation as the original denial about needing documentation”

 

Provider’s report submitted titled “Psychological Consultation” states the injured worker was seen for an intake and assessment taking 1.0 hour with prolonged face to face taking an additional 45 minutes.

 

Psychological testing was administered under constant supervision. The total administration time took 3.0 hours, and the scoring and interpretation took 2.0 hours. ·

 

CPT 96101 -Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

 

. Provider documents all tests administered along with scoring and results in the report submitted.

 

A total of 5.0 hours for psychological testing.

·

Based on information reviewed, reimbursement is warranted for codes 99205-25, 99354 & 96101-59

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_301-600/CB15-0000343.pdf>

 

 

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One place for all your notes and information

WC: Liens W/O Activation Fee Will Not Be Dismissed W/O Notice From DWC

Thursday, July 2, 2015

7:15 AM

Regardless, of the injunction being vacated in  Angelotti Chiropractic, Inc., et al. v. Baker, et al.,  that prior acted to prevent the DWC from enforcing the lien activation fee, it will not be reinstated for Lien Claimants until the DWC posts a notice.

 

A lot of speculation  and anticipation as to what will happen in the near future, based on the recent decision that found the lien activation fee of a $100.00 constitutional and thereby set aside the injunction. Some have stated, that after the appeal time process for the decision has expired, and the decision is final, that it will be a free-for-all for the defense to get dismissals of liens, this is incorrect. 

On November 15, 2013, the DWC / DIR issued a bulletin, (which is law) as to its' policy, stating  that it would no longer require and or collect a lien activation based on that injunction. Therefore, that  law and policy in this "Newsline", is the law as written, until the DWC states it will start collecting and or requiring a lien activate fee.

 

First, the Newline of November 15, 2013  , as of today, stands until changed, second our DWC is not that childish to take advantage of a valid challenge and seek revenge on Lien Claimants for challenging the statute. Lastly, due process  and just common sense of fairness mandates sufficient notice, so Lien Claimants can adjust.

 

"Lien claimants whose liens were subject to the activation fee requirement will not be required to pay the $100 fee in order to appear at a hearing or file a Declaration of Readiness to Proceed (DOR) regarding a lien": From DWC / DIR November 2013

 

Even the DWC knows, that there exists good and bad for all parties and now more than ever it is coming into light ( not a pretty sight to see). Therefore, the DWC will not penalize  good providers who relied on the above bulletin, by causing them to fall into massive defaults and or expenses  of millions of dollars without proper notice of its intent, as both valid claims exist and some not so.

 

For the common sense challenged out there, the law that was in effect, that stated all liens not showing a lien fee by January 2014 would be dismissed by operation of law, that did not take place because of the injunction, it is not even a consideration at this point.  As the recent decision does not create a time machine, as if the injunction never existed, as  January 01, 2014 came and went and everyone complied with the law then in effect at that time.   We  all obeyed the law, including the DWC  and relied on that injunction,  which was the law at the time. Therefore, to believe that there is even a remote possibility  that all liens not showing a lien fee are dismissed by operation of law because they failed to pay lien activation fee  by January 01, 2014 , well, I just do not have the words for that kind of thought process, in writing anyway

 

'In short, you cannot create a forfeiture for those who complied with a law, during a time period,  when it was later determined the law was not valid , for those who acted on reliance of that law. Even if it is just an injunction to stop the enforcement of a law,  as it acted to stop compliance with and  was relied on by all parties (DWC January  2013 Directive) . Therefore, it cannot be said they voluntarily did not comply to  justify a forfeiture i.e. dismissal of liens for failure to pay an activation fee of January 01, 2014.

 

 

In work comp today, we are seeing that some insurance companies and defense attorneys are unfairly  taking advantage of SB 863, while others are great. Just like we have bad and good providers, who have taken advantage, but  most are just trying to get it right, those are the ones we cannot forget about, nor can we throw them to the lions.

 

Therefore, to believe the absurd, that the DWC will be a part of a childish tactic is insane, i.e.   that all liens without a lien activation fee will be dismissed after the appeal time has  expired without proper notice from the DWC.  If such action was to take place, it would even have the Appeal Courts  who  decided against the injunction shaking their head in disbelief, and  lawsuits would be  filed in mass by lien claimants,  no, it will not happen that way.

 

Now at the WCAB, some may try the idiotic argument that since the injunction is no longer, then the above newsline / law / policy  is invalid, wrong. Regardless of the underline reason that motivated the DWC policy,  the DWC stated they will not require a lien activation fee, and that remains law until they send notice out that it has changed, regardless of the underline reason for the policy of not requiring the  lien activation fee.

 

 The DWC, DIR, nor the WCAB will not allow or encourage  chaos,  that would be exactly the result if the unthinkable happens and the DWC does not send out notice of intent to enforce and  a sufficient time and opportunity for providers to adjust to the new ruling.

 

The DWC, DIR and WCAB, has always been more than fair in their notice of a change  of enforcement of a law, both, new and old. There would be no reason for them to change that now, it would be out of character for them to do anything but to ensure  sufficient notice and time to adjust in this fact circumstance.

 

The decision discussed above just stated it was Constitutional to require a lien activation fee, it did not order the enforcement of it. When the time to appeal has expired and a final order is had, then the DWC /DIR has to indicate their intent to enforce a law that prior, they stated would not be enforced, a step process if you will.

 

Not to worry,  there will be plenty of time to panic, but the DWC, DIR, and WCAB will not let the process be unorganized, nor absent sufficient time and notice for payment of the lien activation fees, before dismissals start taking place.

 

by: www.workcompliens.com

 

 

 

Pasted from <https://www.linkedin.com/pulse/wc-liens-wo-activation-fee-dismissed-notice-from-dwc-boggan-jd>

 

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ML104-95 Evaluation, 96101 and 96118

Saturday, July 4, 2015

3:14 PM

 

 

    ANALYSIS AND FINDING

     

    Based on review of the case file the following is noted:

     

    • ISSUE IN DISPUTE: Provider seeking remuneration for ML104-95 Evaluation, 96101 and 96118 Psychological Testing performed on Injured Worker 10/07/2014.
    • Claims Administrator reimbursed $0.00 of $6,331.45 with the following rational: “Claim denied and is currently in litigation.”
    • May 29, 2014 Letter from Claims Admin Legal parties, addressed to the Provider indicated the following: “Defendants do not believe that the applicant is entitled to a Psychiatric Panel at this time.”
    • August 12, 2014 Letter to Provider from Claimant’s Attorney requesting PQM Psychological Evaluation to include Causation and Apportionment.
    • Court Order, 07/17/2014, signed by Workers ’ Compensation Administrative Law Judge  "Granted "the following: “Applicant to go to PQME Eval w/ (Provider) to resolve psych issues.”
    • Provider is the PQME evaluator stated in the court order.
    • ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity facto

    Med Legal OMFS

    • ML104 criteria when compared to abstracted information provided on the Fee Disclosure and

    PQME Report revealed the following:

     

     

     

    1. Two or more hours of face-to-face time by the physician with the injured worker. Criteria Met
    1. Two or more hours of record review by the physician “8”hours Criteria Met
    1. Two or more hours of medical research by the physician. Criteria Not Met
    1. Four or more hours spent on any combination of two complexity factors (1)-(3), which shall count as two complexity factors.
    • Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor. Criteria Met
    1. Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors. Criteria Not Met
    1. Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation. Criteria Met, page  57 of PQME Report.
    1. Addressing the issue of Apportionment under the following circumstances: Criteria Met-Percentage of Apportionment Indicated, Page 61 –63 of PQME Report.
    1. Addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances: Criteria Not Met.
    1. A psychiatric or psychological evaluation which is the primary focus of the medical -legal evaluation. Criteria Met
    1. Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section 4610. Criteria Not Met.

    ·

    • Criteria Met for ML104.
    • CMS 1500 reflects 96118 x 1 unit & 96118 x 1 unit = 56.68
    • 96118 Code Description: Neuropsychological testing (eg, halstead-reitan neuropsychological battery, wechsler memory scales and wisconsin card sorting test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
    • CMS 1500 reflects 96101 x 1 unit, 96101 x 1 unit and 96101 x 1 unit = $149.37
    • 96101 Code Description: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.
    • Page 41 of PQME report indicates: 3.25 hours of “Psych Testing.”
    • QME abstracted information indicates 96118 x 1 unit
    • PQME abstracted information indicates 96101 x 2 units
    • Page 3 of PQM report indicates the following timing:
      • Face-to-Face with applicant (history and mental status exam): 4 hours
      • Record review and review of prior reports and significant commentary on medical records: 8 hours
      • Report Prep Time: 12 hours
      • Total time: 24 hours
    • 3 Hours are subtracted  from the overall time as 96118 x 1 unit and 96101 x 2 units are “per hour codes” and the value of the Physician’s time is included within the relative value of each code. Total Revised Time: 21 hours /84 Units

     

    Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_301-600/CB15-0000302.pdf>

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

ML104

$6,000.00

$0.00

$6,000.00

96

 

$5,250.00

 

96118

$56.00

$0.00

$21.33

2

 

$56.00

 

96101

$149.37

$0.00

$21.33

3

 

$149.37

 

 

 

Machine generated alternative text: Date of Service: 07ì26’2014
Med legal Services
$6000.00
Plan Dispute Assist
Allowed Amount Surgeon
$0.00 $6000.0 N/A
$0.00 $21.33
IVorkers’
Units Comp
Allowed
96 $5.250.00
Prodder
Bified
Service
Code
ML 104
96101
$149.37
96118
$56.00
$0.00
$21.33 N—A
2
$56.00
Med. Legal OMFS
Notes
Refer to Analysis
NA
3
$149.37
X2Units
Med. Legal OMFS

 

 

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WC: How to Setup a Medical Practice under SB 863 in 2015

Sunday, July 5, 2015

8:43 AM

Each setup in the process of treatment and collections is a separate category, that has its own requirements in the practice of medicine under the present laws under the Work Comp system.

 

Now in 2015, we have discovered that there are great collection companies, great hearing reps and great billing companies, but we also learned the opposite is true. In addition, Providers are bombarded with stories, some true, others coupled with sales and puffing of finding ways around the laws, so to know where to land for Providers, is not simple.

 

Therefore, for Providers, they have to put blinders on, as to short cuts around SB 863 and protect their medical practice.

 

Although, there are several types of Providers that require specialized organizational procedures, we will address in general, the organizational processes under SB 863.

First, make sure all treatment is within the guidelines, denied and or admitted. Now for some, they might see this as a restriction in the treatment they are providing or want to provide, this is untrue and one of several major misconceptions spreading throughout the industry.

 

The reason for the documentation in accordance with the treatment guidelines for admitted, denied and contested liability cases, is that the majority will paid fee schedule plus penalties and interest.

 

Now, California has adopted the MTUS as the bases for determining the parameters of medical treatment limits, however by statute and by practice of the IMRs (Independent Medical Review), those limitations have been taken off and expanded into; ODG, ACOEM, and any applicable published medical papers.

 

So basically, as a medical provider, I can get any treatment authorized and determined medically necessary as I deem necessary for the treatment of the injured worker, but it has to be documented, now this is extremely important in denied cases, which we will get to. Example: let’s take compound medication as an example, we know most are denied, however if I am a Provider who believes in its necessity for treatment of injured workers all I have to do document the need more than other services, which we know is not happening today.

 

Then, I am going to ensure that services are authorized,  and  separate, admitted injury cases, from denied cases and contested liability cases.

 

In admitted cases, the laws ensures I get paid fee schedule and penalties and interest for late payment, that is what SB 863 guarantees me, and if this is not happening, it is a Provider error in billing and like services, that simple.

 

In practice, there are 3 extremely important documents that are essential to my practice at the treating stage, authorization, IMRs and any notice of transfer into an MPN, these documents are essential in every case, absent the importance of these documents and denial of treatment and loss of payment are the results every time.

 

As a Provider, I have to resolve myself to the fact that I will have to actually file IBRs, as this is essential to ensure payments to fee schedule plus penalties and interest, this is not an option in today's practice of industrial medicine, it has to be done.

 

If one is not getting treatment authorized on admitted injuries, the Provider is making mistakes, if a Provider is not  getting paid fee schedule and penalties and interest for late payments for admitted cases, the provider is making mistakes, that simple.

 

This, in  fact, is where we saw  and are seeing extreme losses by providers, simple fee schedule issues, even when EOR states 0 payments are going to lien and resolving for 10 cents on the dollar, because some cannot master the second review and or the IBR process, which is the simplistic of all the processes under SB 863. Also, this is where we have millions of dollars in receivables that, by law are not collectable, because no proper second review or no IBR done in the time limits.

 

Now, the reason why one documents the guidelines and or justification for treatment in denied cases is  because if the case becomes admitted or if an issue is overcome, the services are subject to a retrospective review by law, which is of little help if the services were not documented in accordance with the guidelines, this also lessens the need to file a lien, i.e., allows orders for payments without liens or lien time filing limits.

In addition, treatment within the guidelines and or justification, is essential for overcoming issues of treatment outside an MPN.

 

Now, I move onto billing, Providers are billing incorrectly,  not billing correctly or not billing for review of medical records ( not under old 2013 codes  but under 2014 codes), incorrect modifiers for services with Evaluation and Management. It is not so much the billing codes used that is the problem, but the medical reports are not justifying the billing codes, as, this is something new taking place in the last 3 years that did not exist prior, to the degree it is today, this has to be fixed.

 

Lastly, a Provider has to get reports, if a file is settled for 10 cents on the dollar, a Provider  needs to know why, so it does not become common place, as it is today.

 

Above is just a summary which has to be done, the system is not going to get more lax in the future, but more discipline as to what is required. SB 863 may not be fair in some of its provisions, but the point is, that a lot of these losses can be attributed directly to the Providers in not understanding the system, nor applying it correctly, or relying on the wrong place for guidance.

 

by www.workcompliens.com

 

Pasted from <https://www.linkedin.com/pulse/wc-how-setup-medical-practice-under-sb-863-2015-richard-boggan-jd?trk=mp-reader-card>

 

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WC: Lien Law Out for 20 Years, Never Used, Just to Complicated to Get?

Sunday, July 5, 2015

8:57 AM

When I hear a Provider who states their receivables are down, or a collection company having issues with collections, I know part of the problem is getting hold of all the laws, not just understanding them but how to put them into play. 

 

Example: below was put out by the DWC at the end of 2012, showing how liens were actually filed by operation of law, however within the  20 years or more that this labor code has been  in existence, one could not find one instance where a provider used it as it was written. Even after reading the below, most will have issue on how it comes into play, as it does not stand alone (i,e, other laws have to accompany it), even though it could save millions of expired lien files.

 

That is were we are today extreme complications of laws, but they are there,  they are many, and the below is one example of hundreds of laws (and I  mean hundreds, conservatively ) providers are not putting into play. One of the main laws few seem to get is getting an order for payments when time for lien filing has expired, without a lien being filed, that, is actually a lot cleaner and clearer under SB 863, but seldom, if ever  used.

 

Current Labor Code section 4904(a) provides in substance that if a defendant has written notice of a claim that would qualify as a lien, such notice constitutes a lien. Current section 4903.1(b) provides that when a compromise and release agreement (C&R) or stipulated Findings and Award (stip F&A) is submitted to the WCAB, a party shall “file” with the WCAB any lien that was “served” on it. Current section 4903.5 establishes time limitations on when a lien may be “filed.” The proposed amendments to Rule 10770 described in the paragraph above, in effect: (1) interpret section 4904(a) to mean that written notice to a defendant of a lien does not equate to “filing” the lien with the WCAB; (2) interpret section 4904(a) to mean that a defendant does not have “notice” that a lien is being asserted if the lien claimant is silent for at least three months after a defendant has made some payment to it; and (3) interpret section 4903.1(b) to mean that, after a C&R or a stip F&A,a defendant is not required to “file” any liens served on it if the lien claimant fails to make any additional written demand within three months after the defendant has made some payment. These interpretations are consistent with the language and intent of these statutes and give greater force to the statute of limitations provisions of section 4903.5.

 

Now to get what they are saying  you have to read the above more than once as they distinguish what is considered filing with the board (first bold) and when the obligation to file a lien by the Defense is vested (second bold)-- also some changes were made under SB 863 but still workable.

Warning: do not try this without trained instructions, as there are certain other elements  / laws that must be shown and incorporate  that is beyond the information posted here.

 

by: www.workcompliens.com

 

At this point is unimportant why providers are suffering losses, but in a nutshell, it is that the system has not been mastered by a great many – not even close. Therefore, most are reverting to 2012 and prior tactics that was the intent of SB 863 to dissuade and do away with by defaults into economic losses, therefore the predicable is happening.

 

First let’s start by disclaiming some myths in this industry.

 

1. I read a post where a Provider stated that she would not take new patients because she would not get paid for review of medical records. Untrue, although the billing code used prior to 2013 for review of medical records is no longer valid , Providers still get paid for review of medical records, differing coding, differing authorizations, differing medical necessity, and always under medical-legal. There are over 15 IBR decisions for dates of services in 2014 and 2015 where the provider was awarded additional monies for review of medical records, and compared to the number of actual IBRs that is a high percentage.

2. I have to file a lien in an admitted injury case – untrue

3. Have to file lien for medical-legal services – untrue

4. Have to treat on a UR denial- insanity

5. Cannot get compound medications authorized- untrue

6. Cannot get paid more than $119.95 for drug test – untrue

7. There are many more misconceptions what can and what has to be done under SB 863, but one thing is clear if one does not now how to achieve justice no is going to show you as most don’t know.

 

First the system was not meant to punish Providers, although some are letting that happen themselves, by no knowing the laws, What the system set out to do is punish through defaults those who use the same tactics  they used prior,i,e, no detail, no justification for treatment in the medicals and no following the 2nd review and IBR process.

 

There should never be a UR denial if Providers can justify their treatment requests in the medicals, in admitted cases Providers should get paid fee schedule and penalties and interest.

 

In short, Providers who claim they took a hit under SB 863 including the 2014 fee schedule are wrong, as there is not a service or a Providers time that is not payable under the fee schedule, so providers should be getting paid more and more treatment authorized . It just takes learning the laws, procedures,  IBR decisions and IMR decisions.

 

Providers who have mastered SB 863 are not suffering losses, but are doing better than they had any time prior, the problem is that only a few providers have master SB 863.

 

 

Summary of General Procedural Laws Below

Procedures for Collection Dispute Files from Birth to Death

 

1. Receives EOB

a. Initial billing the carrier has 15 days for electronic billing to pay and or object and 45 days by paper billing.

i. Failure to pay or object within time limits means carrier waives right and provider gets paid but only if case is not a denied injury and provider was informed of the denial. (Stated in October 23, 2013 Adopted WCAB Rules)

b. Partial Pay or 0 pay if only dispute is the amount of payment 90 days to request a second review by form (note: partial payment alone does not mean that it automatically a second review process)

i. Failure to do a second review means carrier no longer responsible for any further payment

c. If for medical legal services have to ensure only issue is amount of payment and not contesting medical legal on other grounds to go to 2nd review IBR process

d. If medical legal and issues other than reasonable reimbursement

i. Carrier has to object in 60 days

ii. Provider has to object in 90 days to defense objection

iii. Defense files a “Petition in 60 days”

1. Defense Fails to file a petition provider can file a the “Petition for Determination of Non-IBR Medical-Legal Dispute” ,Failure to object to medical legal reduction and or defense means carrier responsible for not further payments

2. Court can either issue an NOI on the petition for set matter for hearing

3. Medical legal provider now has to attend all hearings but no lien fee

e. If billing is incomplete the carrier can treat it as complete or treat it as incomplete then the 90 days does not start until completed bill is submitted.

f. Carries gets second chance to deny liability

i. Submitting of second review carrier can defer a request for second review stating contested liability (any issue that would prevent the provider from being paid or deny liability) even if not stated on initial bill review.

ii. If the carrier does not defer within 14 days the provider gets paid fee schedule and carrier waives their right to contest to amount paid (provider still has the burden to prove fee schedule and or reasonable reimbursement can go to WCAB)

iii. Any payments not in dispute carrier has 21 days to pay or penalties and interest attach

g. After response to second review provider has 30 days to request a IBR, pay $195.00 which if determined any additional money owed to provider an order the 195..00 also awarded to paid by carrier

h. IBR can be determined ineligible for IBR if found a large part of  fee is returned to provider

i. If IBR makes a determination it is an order and can only appealed to WCAB in 20 days under specified conditions

j. Consolidation of IBR requests allowed under certain fact circumstances

 

2. If the billing and payment is denied because of medical necessity issue UR deferred a partial payment no matter the amount acts as a retrospective UR approval of the treatment requested and the provider gets paid fee schedule, may now be subject to 2nd review if amount of payment still in dispute

 

3. If EOB states that the claim is denied, contested or states any other reason for non-payment or partial payment additional procedures are required

a. If for medical legal billing and or services then the procedures are time sensitive for “Petition for Determination of Non-IBR Medical-Legal Dispute”, takes place.

b. Failure to comply with time requirements means the provider waives the right to any further payment and or payment at all. If carrier fails to comply with time requirements and or objections, waived and provider gets paid fee schedule.

 

4. If contested liability issues or denied injury certain procedures must be followed to maintain value of that collection dispute files

a. If issue is that the bill was denied because UR denial and no IMR request after in 30 days treatment not payable

b. If the carrier fails to do a UR timely or not at all UR reports not admissible and provider gets paid for treatment unless denied claim as to non-industrial injury and provider was informed.

c. If UR was deferred because of a contested liability issue, partial payment within 30 days of the request for UR provider gets paid and then may be subject to second review if after amount of payment in dispute.

d. If contested liability issues such medical treatment and MPN issues resolved by expedited hearing the RFA treatment request is subject to UR if treatment already provided carrier must do a UR in 30 days or waive the right to object to medical necessity.

e. If treatment had not been provided that provider must re-submit a RFA for UR review unless carrier consents to medical necessity.

 

5. Contested liability can be resolved by the case in chief closing documents and if medical necessity still in dispute has to go back to UR

 

6. If second review had been deferred based on contested liability time to do second receive is on the provider when served with that court order resolving contested liability issue.

 

7. If contested liability has not been resolved by court order, consent of parties or closing documents or “Petition for Determination of Non-IBR Medical-Legal Dispute”, the WCAB assistance is required .

 

8. If date of service prior to July 01 2013 have 3 years to file a lien from date of services

 

9. If date of services is after July 01, 2013 you have 18 months

 

10. If filing a lien must pay a lien fee of $150.00, to get reimbursed for that lien fee Labor Code § 4903.07.

(a) A lien claimant shall be entitled to an order or award for reimbursement of a lien filing fee or lien activation fee, together with interest at the rate allowed on civil judgments, only if all of the following conditions are satisfied:

(1) Not less than 30 days before filing the lien for which the filing fee was paid or filing the declaration of readiness for which the lien activation fee was paid, the lien claimant has made written demand for settlement of the lien claim for a clearly stated sum which shall be inclusive of all claims of debt, interest, penalty, or other claims potentially recoverable on the lien.

 

(2) The defendant fails to accept the settlement demand in writing within 20 days of receipt of the demand for settlement, or within any additional time as may be provide by the written demand.

 

(3) After submission of the lien dispute to the appeals board or an arbitrator, a final award is made in favor of the lien claimant of a specified sum that is equal to or greater than the amount of the settlement demand. The amount of the interest and filing fee or lien activation fee shall not be considered in determining whether the award is equal to or greater than the demand.

 

11. If seeking the WCAB assistance must sustain burden of proof -- all defaults and waiver of time requirements to object from the IMR and IBR process can be heard at the WCAB

 

12. Just because a lien hearing and lien trial was held the provider may be required to go back to the IMR and or IBR process after contested liability issue is resolved.

 

13. Unpreparedness at the WCAB results in sanctions

 

14. Unpreparedness at the WCAB results in low settlements

 

15. A missed issue or lack of knowledge of case law results in low settlement and or take nothing at the board.

 

16. Appearing at the board when was required to got to UR and IBR process because contested liability issues was resolved by court order prior to lien hearing results in sanctions and a take nothing

 

17. The WCAB will not educate the provider in which laws allow them to get paid fee schedule

 

18. The WCAB will not rule on evidence not accepted or listed on pre-trial conference statement

 

19. The WCAB will only make decisions on rules based on evidence accepted and law issue brought up

 

20. Recons are 20 plus 5 and must only address evidence submitted at trial and those issues raised at trial

 

21. There are over 20 pleadings and petitions at the WCAB that must either be timely submitted and timely responded to or sanctions and loss of rights results.

 

22. All substantive laws and procedures laws are being enforced at the WCAB failure to comply results in sanctions

23. Insurmountable case laws address almost every possible issue regarding reimbursement must be known.

 

24. If the case in denied by closing documents the provider has the burden to show injury industrially related.

 

25. A collection disputed file can be valued from 0 to fee schedule depending on the knowledge and compliance with the time requirements and providers of the party asserting the right to reimbursement.

 

 

1. Once all the procedures and time requirements are meant and or objected to and we end up with a collection dispute file the file in now in the hands of a collector to resolve prior to the WCAB process.

 

2. As a collector since 2012:”Torres”, case the collector takes on the role of trying to resolve the dispute and developing the file for both collections and or the WCAB.

a. Lien claimants burden of proof to prove causation, medical necessity and reasonable reimbursement.

b. Identify why the collection dispute files shows no payment and or partial payment.

i. Denied injury carrier stated the injury did not happen or was not related to a work injury.

ii. Carrier stating admitted injury but denied body part

iii. Carrier stating the applicant failed to follow procedures such reporting injury and filing a claim after termination

iv. Treatment not authorized

v. Denial of utilization review.

vi. Treatment outside the MPN

vii. Other procedural and substantive violations that would preclude the provider from payment for the services provided

 

3. Collector must increase the value of that file by overcoming and or responding the reasons for the carrier failing to pay.

 

4. Initial Review of Collections file

a. See if lien filed

b. See if time to file a lien is approaching

c. See if treatment was authorized and or what happen to the provider’s request for authorization.

d. See if case in Chief Resolved

e. See if case in chief resolved reason for denial of payment

f. See if any expiate hearing resolving reason for non-payment

 

1. For 2013 dates of services significant events that may change the status of the case and increase value:

a. Any court order

b. Any IMR and or IBR decision

c. Any UR determination (retrospective review for deferred UR)

d. An result from an Expedited Hearing regarding treatment and or MPN issues

e. Medical legal reports may case consent to resolve contested liability issue

f. C&R / Closing documents resolving case between the employer and injured worker

 

2. For dates of services prior to 2013 significant events that change the status of a case and increase value of collection file.

a. Any court order

b. Any expiated hearing

c. Medical legal reports may case consent to resolve contested liability issue

d. C&R / Closing documents resolving case between the employer and injured worker

 

3. Obtaining necessary information to increase value of collection file:

a. UR reports if no lien can attempt to get from provider

b. RFA can get from provider

c. Medical Legal reports providers may have been served with copies of these reports

 

4. If a lien is filed a “Petition By a Non-Physician Lien Claimant” must be filed with the court to get any medical information that includes QME and AME medical reports

5. Time management for collections

a. Calls to reach goals top priority

b. Manage file to make sure issue identifying issue and documents needed to increase value

c. Documents and issue identification increase collections, increase value of file at collection stag and ensures file is WCAB qualified.

d. Ensuring file are WCAB qualified helps to increase collections as it will not be long before parties in the industrial get the message failure to resolve in ,must case means we are prepared to win at the WCAB (the hammer)

 

6. Management of a collection file is extremely important as to ensure value is not lessened and time requirements are not missed.

 

7. Collector should have the knowledge and experience to know and be able recommend if a collection dispute file is WCAB qualified and make an educated assessment as to the changes of winning.

 

8. Issues for collections and what is need to overcome and or put forth a valid argument for both procedural and substantive law and need to be able to overcome simple dispute issues

The above is just the short sheet

by: www.workcompliens.com

 

Pasted from <https://www.linkedin.com/pulse/wc-lien-law-out-20-years-never-used-just-complicated-get-boggan-jd?trk=mp-reader-card>

 

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Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned

Psychological testing, 5 units: Overturned

Sunday, July 5, 2015

11:56 AM

Decision rationale: The Chronic Pain Medical Treatment Guidelines, 8 C.C.R. §§9792.20 -9792.26, page(s) pgs. 100-101. has the following to state about Psychological evaluations: Recommended. Psychological evaluations are generally accepted, well-established diagnostic procedures not only with selected use in pain problems, but also with more widespread use in chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related. Psychosocial evaluations should determine if further psychosocial interventions are indicated. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. (Main-BMJ, 2002) (Colorado, 2002) (Gatchel, 1995) (Gatchel, 1999) (Gatchel, 2004) (Gatchel, 2005) For the evaluation and prediction of patients who have a high likelihood of developing chronic pain, a study of patients who were administered a standard battery psychological assessment test found that there is a Psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (Gatchel, 1999) Childhood abuse and other past traumatic events were also found to be predictors of chronic pain patients. (Goldberg, 1999) Another trial found that it appears to be feasible to identify patients with high levels of risk of chronic pain and

to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem. (Linton, 2002) Other studies and reviews support these theories. (Perez, 2001) (Pulliam, 2001) (Severeijns, 2001) (Sommer, 1998) In a large RCT the benefits of improved depression care (antidepressant medications and/or psychotherapy) extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status. (Lin-JAMA, 2003) See "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients" from the Colorado Division of Workers' Compensation, which describes and evaluates the following 26 tests: (1) BHI 2nd ed -Battery for Health Improvement, (2) MBHI -Millon Behavioral Health Inventory [has been superseded by the MBMD following, which should be administered instead], (3) MBMD -Millon Behavioral Medical Diagnostic, (4) PAB -Pain Assessment Battery, (5) MCMI-111 -Millon Clinical Multiaxial Inventory, (6) MMPI-2 -Minnesota Inventory, (7) PAI -Personality Assessment Inventory, (8) BBHI 2 -Brief Battery for Health Improvement, (9) MPI -Multidimensional Pain Inventory, (10) P-3 -Pain Patient Profile, (11) Pain Presentation Inventory, (12) PRIME-MD -Primary Care Evaluation for Mental Disorders, (13) PHQ -Patient Health Questionnaire, (14) SF 36, (15) SIP -Sickness Impact Profile, (16) BSI -Brief Symptom Inventory, (17) BSI 18 -Brief Symptom Inventory, (18) SCL-90 -Symp

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_1-10000/CM13-0006218.pdf>

 

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Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned
PSYCHOLOGY
SURGERY
TESTING
PHYSICAL THERAPY
PHYSICAL THERAPY
MEDICATIONS
OTHERS
ACUPUNCTURE
CHIROPRACTIC
DME
Program Files Medical Necessity RFA: Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Diagnostic Left L5
Medial Branch Facet Block QYT 1.00:
Overturned
Program Authorization UR Denials Overturned by IMR:
PROSPECTIVE REQUEST FOR 1 QUALITATIVE 12 PANEL
URINE DRUG SCREEN :Overturned