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.
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.
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
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.
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.
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
get compound medications authorized- untrue
get paid more than $119.95 for drug test – untrue
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.
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.
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.
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.
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
Summary of General Procedural Laws Below
Procedures for Collection Dispute Files from Birth to
billing the carrier has 15 days for electronic billing to pay and or object and
45 days by paper billing.
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)
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)
to do a second review means carrier no longer responsible for any further
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
medical legal and issues other than reasonable reimbursement
has to object in 60 days
Provider has to object in 90 days to defense objection
Defense files a “Petition in 60 days”
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
can either issue an NOI on the petition for set matter for hearing
legal provider now has to attend all hearings but no lien fee
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.
gets second chance to deny liability
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)
payments not in dispute carrier has 21 days to pay or penalties and interest
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
i. If IBR
makes a determination it is an order and can only appealed to WCAB in 20 days
under specified conditions
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.
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.
contested liability issues or denied injury certain procedures must be followed
to maintain value of that collection dispute files
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.
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.
treatment had not been provided that provider must re-submit a RFA for UR
review unless carrier consents to medical necessity.
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
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.
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
9. If date
of services is after July 01, 2013 you have 18 months
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:
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.
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.
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.
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
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
Unpreparedness at the WCAB results in sanctions
Unpreparedness at the WCAB results in low settlements
missed issue or lack of knowledge of case law results in low settlement and or
take nothing at the board.
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
WCAB will not educate the provider in which laws allow them to get paid fee
WCAB will not rule on evidence not accepted or listed on pre-trial conference
WCAB will only make decisions on rules based on evidence accepted and law issue
are 20 plus 5 and must only address evidence submitted at trial and those
issues raised at trial
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.
substantive laws and procedures laws are being enforced at the WCAB failure to
comply results in sanctions
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
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.
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
claimants burden of proof to prove causation, medical necessity and reasonable
Identify why the collection dispute files shows no payment and or partial
injury carrier stated the injury did not happen or was not related to a work
Carrier stating admitted injury but denied body part
Carrier stating the applicant failed to follow procedures such reporting injury
and filing a claim after termination
Treatment not authorized
of utilization review.
Treatment outside the MPN
procedural and substantive violations that would preclude the provider from
payment for the services provided
Collector must increase the value of that file by overcoming and or responding
the reasons for the carrier failing to pay.
Review of Collections file
a. See if
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
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
2013 dates of services significant events that may change the status of the
case and increase value:
b. Any IMR
and or IBR decision
c. Any UR
determination (retrospective review for deferred UR)
result from an Expedited Hearing regarding treatment and or MPN issues
legal reports may case consent to resolve contested liability issue
/ Closing documents resolving case between the employer and injured worker
dates of services prior to 2013 significant events that change the status of a
case and increase value of collection file.
legal reports may case consent to resolve contested liability issue
/ Closing documents resolving case between the employer and injured worker
Obtaining necessary information to increase value of collection file:
reports if no lien can attempt to get from provider
b. RFA can
get from provider
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
management for collections
to reach goals top priority
file to make sure issue identifying issue and documents needed to increase
Documents and issue identification increase collections, increase value of file
at collection stag and ensures file is WCAB qualified.
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)
Management of a collection file is extremely important as to ensure value is
not lessened and time requirements are not missed.
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.
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
is just the short sheet