2017 newsletter provider issues

2017 Collections Dispute Newsletter www.workcompliens.com Page 1
WC: Summary of
California Workers'
Comp System for
Providers Explained in
Steps -- Including
Advantages Taken By
Both Parties
1. Independent
Medical Review (IMR)
Process Includes, the
request for authorization,
utilization review, IMR
process all based on
medical necessity based on
MTUS and overshadowed
by evidence based
medicine (EBM)
2. Transitional arrow
to next step
3. Starts by
Submitting Request for
Authorization form (RFA):
This is done by form for
dates of services 2013 on
forward except for the first
part of 2013 if date of
injury prior to 2013. Prior
to 2013 a PR2, Narrative
report, or document
shown on top, for a
request for authorization,
and initial report. Only a
treating physician can
request authorization, this
causes some problems
with the Defense as they
are shown a RFA by an
Ancillary Provider and
see no UR so they buy the
argument of untimely
UR, which is wrong, if
not proper request by
proper party no need to
respond. Second issue is a
RFA cannot be by a
electronic signature or cut
and paste signature unless
by consent by the
insurance. All services
must have a RFA, trying
to by-pass this process,
means the Insurance does
not have to pay for those
services. In addition a
Ancillary can get the
results of a UR by an
INSIDE THIS ISSUE:
PROCEDURAL PROCESS IMR, IBR AND WCAB
2017 WORKERS’ COMPENSATION LIEN
CLAIMANT COLLECTIONS NEWSLETTER
SUBSCRIBER FOR COLLECTIONS NEWSLETTER
2017 Collections Newsletter For more News and Educational Materials Visit www.workcompliens.com
Richard J Boggan JD Juris Doctor, Law publisher of "Work Comp Collections Newsletters “Author of “Lien Claimants’ Representative Guidebook” published each year since 2001
2016 A-Z all Provider Issues IBR, IMR and
WCAB Decisions Plus SB 1160 Petitions and
Responses Evidence Based Medicine book for
every
service, medication, DME, surgery, testing,
referrals and more, done in the same format as
below now available 3 years in the making see
below picture sample that is done for all
services, medication, DME, surgery, testing,
referrals and more
Go to www.workcompliens.com

(72 hours or less)
3.Retrospective (30
days or less)
18. Transitional
arrow to next step
19. After UR
Process if denied,
modified Adjuster will
send request for IMR
form filled out by
adjuster to the applicant
or the applicant
representative, it is the
obligation of the
adjuster to make sure
all medical reports are
submitted. 30 day to
submit. At the start of
2013, Applicant
Attorneys, would ask
the PTP to help submit
the IMR, but few did so
the practice stopped.
The only exception to
who can submit an IMR
is an emergency room
physician who can
submit one without the
applicant. ( after a UR
denial of retrospective
review)
20. Blank
21. Transitional
arrow to next step
22. Transitional
arrow to next step
23. 30 days to
request an IMR fees
paid by Adjuster /
Insurance Company (all
filed out sometimes, but
a Provider can add a
report if all parties
served before or at the
same time submitting.
24. Transitional
arrow to next step
25. 1.Goes to
Director if eligible goes
to IMRO 2.Assigned to
IMR 3.Issues decision
4.May appeal in 20
days to WCAB
26. UR has a life
insurance is prohibited
from sending them the
complete UR as it puts
forth protected medical
information, even though
it’s done today, they are
charged with getting the
results from the PTP, or
treating Provider. ( see
definition of physician
under regs)
4. Transitional
arrow to next step
5. Adjuster has to
notify in 5 days if
incorrect form: if the
Provider uses an
incorrect form and it is
clear it is a RFA by title
of page and all required
information to do a UR,
the insurance has 5 days
to reject that improper
form, or it is deemed
accepted. NOTE: Unlike
the IBR process, a
untimely response to a
UR request does not
establish medical
necessity, there is only
one default that
establishes medical
necessity and that is
when there is a partial
payment within 30 days
for a RFA ( this is
usually found in
requests for
retrospective review) ,
all other issues medical
necessity is always on
the Provider to
establish.
6. Transitional
arrow to next step
7. Adjuster Actions
8. Transitional
arrow to next step
9. Not send it
through utilization review
because disputed liability
issue –goes to lien
process -deferred- This
regulation was intended to
take even denied case later
admitted away from the lien
process in keep it in the IMR
process, which means that
after a court order or by
agreement that a denied case
first denied is admitted, if
services provided the
adjuster was to do a
retrospective review without
any action by the Provider.
This helps Providers in some
cases if they did not file a
lien and was past the time to
file. In addition, it is
important to note that
depending on the language of
a UR denial, based on an
MPN issue may be a waiver
of an MPN defense
depending on how worded ,
who the UR is addressed to,
and where on the document
does it state MPN Provider.
10. Transitional arrow to
next step
11. Defective URs,
normally means not all
medical records were not
considered, some insurance
companies incorrectly state
in a UR that "reviewed all
submitted records" or like
language, this is incorrect,
must list each and every
medical record by name
reviewed, therefore if not
considered defective,
however a defective UR does
not give way to a allowable
lien but must be used if an
IMR upholds a UR denial
and the Provider knows all
medical were not attached,
which is the number one
reason why IMRs uphold UR
denials, lack of
documentation. It is also
important to note that proper
documentation, even though
authorized services can effect
payment issues when it
comes to billing. This is a
fault in the industry by those
who take short cuts, they
believe they game the
system by a short cut only to
find the short cut cost them
payments when that process
is approached, this is more
noticeable in medical-legal
issues, where one gets over
the request by a party but
does not see it all the way
through , so a $10,000.00
payable bill then becomes a
$1,000.00 settlement, very
common.
12. Sends to Utilization
Review (UR Process), the
insurance UR use MTUS,
unless the Provider in
medical documentation
gives reason to expand
treatment to EBM. One
reason that generic medical
reports have harmed injured
workers and Providers alike.
One can actually tell by a
format of medical report that
either a Provider
documented or not and
whether services requested
are documented without
even reading the report as
there a large part of
Providers use the same
generic reports.
to next step
14. If untimely can file a
lien for WCAB, the issue
here is that still even if
untimely the Provider has to
show services within EBM,
so getting it right at the start
would be the proper way and
not look for untimely URs.
to next step
to next step
17. Time Frames
1.Concurrent , Prospective
(5 days or less) 2.Expedite

span of 12 months or
change in documented
medical condition: This
one of the most
important laws
regarding the IMR
process, but for different
reason than most think.
Example: I request a
epidural injection, it
comes back denied
because no MRI, I do an
MRI and can now
resubmit another RFA
immediately, for an
epidural injection as it is
a change in medical
facts affecting the UR
denial.Why Providers
do not apply is for the
simple reasons, maybe a
UR denial will ot say no
MRI but the IMR
upholding will, but that
takes too long and the
Provider already did the
injection before the MRI
decision. for a Provider
to use the above law
they have to understand
EBM, so they know
what is missing even
when not clearly stated
in the UR denials or
waiting for the MRI. Or
say a Provider request
12 physical medicine on
first vist denied because
exceeds number. the
Provider can immediate
for a RFA for 6 as
required for trial to
show objective
functional improvement
(is not a statement but
must show facts, as to
what improvements) ,
not same treatment.
However, one has to
understand EBM to
apply this law, as abuse
of it without a valid
cause will get a Provider
kicked off any MPN.
Example:The criteria for
the use of epidural
steroid injections are as
follows:
1) Radiculopathy must
be documented by
physical examination
and corroborated by
imaging studies and/or
electrodiagnostic
testing.
2) Initially unresponsive
to conservative
treatment (exercises,
physical methods,
NSAIDs and muscle
relaxants).
3) Injections should be
performed using
fluoroscopy (live x-ray)
for guidance.
4) If used for diagnostic
purposes, a maximum of
two injections should be
performed. A second
block is not
recommended if there is
inadequate response to
the first block.
Diagnostic blocks
should be at an interval
of at least one to two
weeks between
injections.
5) No more than two
nerve root levels should
be injected using
transforaminal blocks.
6) No more than one
interlaminar level
should be injected at
one session.
7) In the therapeutic
phase, repeat blocks
should be based on
continued objective
documented pain and
functional improvement,
including at least 50%
pain relief with
associated reduction of
medication use for six to
eight weeks, with a
general recommendation
of no more than 4
blocks per region per
year.
Elements:
• unresponsiveness
to
conservative treatment.
• imaging studies
• clear clinical signs
of radiculopathy and
non-corroborative
findings on imaging,
to next step
28. WCAB Disputed
Liability Process (Lien
Process) Although
most see the lien
process as simple,
based on how the IBR
and IMR process is
supposed to interact
with it is anything but
simple, add to that SB
1160. Lien Process is
supposed to be limited t
contested liability
issues, including
untimely URs and
untimely response to
second review, more
info is needed to truly
understand that
statement. " Contested
Liability Issues", is a
term born under SB 863.
which means denied
claim or any reason if
proven true the Provider
would be entitled to no
payments, however that
does not include failure
to comply with the time
requirement of IMRs
and IBRs, liens are
expressly prohibited if
the only issue is the
IMR or IBR process,
now enforceable
without hearings by
WCAB Judges or
Petition. Therefore, the
main goal of some
Providers who
disregarded the IMR
and IBR process and
filed liens have to use
the laws to pull those
claim back into either
the IMR or IBR process
before they are
dismissed.
29. Will only hear
denied cases, contested
liability issues ,
untimely UR,
Authorization process
and or Defective or
untimely payment , 2nd
review process /
Appeals from IBR or
IMR decisions and
Non-IBR Medical
Legal Disputes –
Including enforcement
of IBR decisions and or
penalties and interest.
Rushing to the WCAB
on filing a lien is
generally not the best
move for Providers,
they have to understand
the IBR and IMR
process and stay in
those 2 processes.
to next step
to next step
32. 2013 Files Lien 3
years from last date of
Service liens filed prior
to July 1, 2013 and after
January 01, 2013, prior
is based on old lien

laws--- for dates of services
after July 1 2013 18 months
to file lien from last date of
service Lien filing fee of
$150 for liens filed on or
after January 01, 2013 –
There are several
complications regarding
liens, first when are liens
not required: treatment for
future medicals, medical-
legal, if closing documents
addresses the medical bills
in question, and depending
on wording if the closing
documents holds the
applicant harmless for all
medicals. With SB 1160 we
are seeing that a lien can be
dismissed without a
hearing, if subject to IBR or
IMR or lack of
documentation showing
treatment outside an MPN
is warranted ( little more to
it but it will be discussed
later on). Presently
Providers have to look at
liens as a discount for
medical services provided,
as IBRs if subject too or
IMRs if subject too give
greater results than
settlements via liens.
Recently there have been
several panel decisions
discussing what happens
when the 3 year travels to
the 18 months of last date
of services, holding the 18
month applies thereby
holding that the Provider
forfeits the 3 years. Now
some will state they are not
collecting on the dates of
services that travel to the 18
months, this is invalid,
Providers do not get to
choose what last date of
services they can apply. In
addition, last date of service
applies to continual medical
treatment without
interpretation, meaning
testing is not continual
medical treatment even if a
second one is done 6
months apart. In 2017, both
the defense and Providers
should use Petitions to
resolve liens prior to
hearings as the issue are too
many and too complex to
leave to oral representation
alone, thus will happen
regardless of parties
willingness or not, as that is
the bases of SB 1160.
33. Medical Legal If Non-
IBR by petition no lien or
lien required if procedures
followed -- like the IBR
and the IMR process the
expediency to resolve
issues without liens, the
medical-legal process was
enacted. However, even
though the "Petition for
Non-IBR Medical-Legal"
has it purpose, some judges
have dropped the ball and
will push the medical-legal
to lien hearings defeating
the purpose to have the
issue resolved immediately.
Now for medical-legals,
IBRs give the better
decisions than the WCAB
which will discussed under
the IBR process.
next step
35. To get lien filing fees
fee must send offer 30 days
prior to filing, win at
hearing for an amount
equal to or greater than the
offer
36. Court order resolving
disputed liability issue may
have to go back to IMR or
IBR process where left off
with time limits
next step
38. Requires a retrospective
review 30 days to
complete if services already
provided review by UR. If
services not provided RFA-
- this where the IMR
process to to restart - or
start anew after deferred
based on a contested
liability issue.
39. UR has a life span of 12
months or change in
documented medical
condition
40-43. Is the process of
going through the IMR
process after a denied
injury and or contested
liability issue is resolved
44. Independent Bill
Reviewer (IBR) Process
the IBR process including
billing and second bill
review is the most
complex process of all
processes because it
touches every possible
issue regarding all issues
that effect Providers and
even case in chief issues.
This is where Providers
lose most of their monies,
in not understanding 0
pays, medical-legals,
objections, MPNs and
how it relates to
authorization, and what
EORs are actually stating
- this becomes more
crucial under SB 1160 to
master the IBR Process
more than any other.
For the defense under SB
1160 even prior, when
settling the case in chief,
at that time the defense
can request petitions for
dismissal for all service
that are subject to the
IMR or IBR and a Notice
to Dismiss can be issued
for liens filed, allowing
adjusters to close files
sooner.
For Providers if they
understand IBR decisions
with relation to IMR
decisions Providers can see
a substantial increase in
monies and services, but
they have to break away
from the idea that they
understand payments or
medical necessity without
the add knowledge of these
IMR and IBR decisions.
This appears the hardest
concept for most in the
industry to get a hold of.
Example would be FCE, I
can show a Provider 50
IMR decisions on
authorization for an FCE,
and show them 20 IBR
decisions that state to be
paid at billed charges, and
still most cannot put it into
play because it does not fit
into what years of
experience or what they
learn at lectures, IBR and
IMRs are new and very
different then what
happened for years, this
concept is a major problem
for most Providers. So
simple, yet so hard to get it
through a block wall of
what most perceive what
they believe they think they
know.

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


45. Provider has 90 days to
seek second review if only
issue is reasonable

reimbursement-(date of
proof of service or date of
proof of receipt or if no
proof of services or receipt
5 additional days from post
mark). Now a second bill
review request is only
mandatory if the only issue
is the amount of payment of
a fee schedule adopted by
the administrative director
or payments under a PPO
contract and or contract for
services. This is collected
by two separate sections
regarding the IBR process
in which states may request
then another states
"If the only dispute is the
amount of payment and the
provider does not request a
second review within the
timeframes set forth in
subdivision (b), the bill
shall be deemed satisfied
and neither the claims
administrator nor the
employee shall be liable for
any further payment"





Now the amount of
payment issue may mislead
some believing that at least
something must be paid to
make it a dispute of
payment, this is a
misguided mistake and a
costly one, as most issues
of 0 pay in admitted injury
cases are subject to the
mandatory second review,
some not, but because of its
lack of use some of these
issue have not been
developed and in fact some
have developed incorrectly.
In addition some of the
regulations regarding
second review does defies
logic, but never-the less it
is the law, example would
be the difference between a
incomplete bill which is
subject to second review as
opposed to a rejected bill
where we have to travel to
the billing laws to find the
difference. That aside there
are many benefits for
Providers to master the IBR
process, but few use it and
accounts for the simplest of
monies lost.
The additional issue with
requests for second bill
review, is that if a Provider
does not use the required
form adopted by the DWC,
the insurance does not have
to respond timely nor pay
timely, therefore all those
who did not use the proper
form and are yelling
untimely response and filed
a lien that defense is not
valid and such liens are
subject to dismissal by law
after notice.
A claims administrator may
respond to a request for
second bill review that does
not comply with the
requirements of subdivision
(d). Any response to such a
request is not subject to the
requirements of
subdivisions (g) and (h) of
this section.
In the statement of reason
for the IBR regulations, it is
stated that the second bill
review request was for the
purpose of limiting appeals
to one, so that an adjuster is
not overwhelmed with
many appeals on the same
issue, however, some MPN
contracts do allow an
addition informal appeal
before jumping into the
formal IBR process, one
would have to read such
internal policy as it is not
common to all insurance
companies.
Second bill review requests
are not an end to the
process but the start, if
additional monies not paid
or not paid to fee schedule,
by report or contract, then
an IBR has to be done in 30
days or the insurance can
close their file and no
additional monies owed, a
waiver.
next step
47. By WCAB adopted
rules of Oct 2013 failure to
respond to second review
within 14 days now a lien
issue and provider gets paid
fee schedule, this is the way
that the regulation was
written at the start of 2013,
"paid fee schedule then in
effect for that date of
service" which made little
sense as it give the
insurance no incentive to
respond timely or not at all.
Therefore, mid 2013 they
took the wording pay fee
schedule and made it a
default law against the
insurance for not respond
or responding untimely,
only 1 of 2 defaults outside
of IBR decisions as to
objections and document
submitted, in SB 863
regulations, against
insurance that increase
penalties for not
complying, the other being
partial payment being made
within 30 days of a RFA
operates as an authorization
of services of that RFA.
However to benefit from
this law proper form and
information must be in that
request for second review,
of which a great many of
Providers did not do until
the start of 2016, some still
not using proper form or
information. The problem
with the default as clearly
stated in the laws, is that it
had not been developed and
the question as to what
forum to use to get the
default, as it has not been
used nor known by most,
which kind of sums up the
entire system under SB
863, most do not know
what they do not know, and
defaulting to what they do
known and missing benefits
under the laws, both by the
defense and Providers
alike.
There are several ways in
which the time limits can
be restarted of the request
for second review, however
these methods are not
written in the laws but
developed by a series of
IBR decisions, therefore,
violating the 90 day rule
may or may not close the
door to start anew the 90
day time limit, important to
know these laws developed
by IBR decisions.

next step
next step
next step
51. After and only after
second review Provider has
30 days to seek IBR by
form failure to do so
operates as a default and
insurance not obligated to
pay anymore.
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52. Request for second
review by form after initial
review of medical bill 90
days or no further recourse
-- failure to comply with
the time requirements
operates as a waiver
communicating in a sense
acceptance what was paid.
A large number of
Providers or Collection
Companies failed to take
these time requirement
seriously, now in 2017 all
those defaults can be
dismissed without a
hearing.
53. Cannot file a lien if
only issue subject to IBR
unless untimely , initially
sanction were to be
imposed for filing a lien
could still be but now a
Judge can dismiss or notice
to dismiss without a formal
hearing or setting for
hearing, even at the case
and chief hearing.
next step
55. Fee for IBR $195.00 if
the Provider wins an IBR
decision an order issues for
reimbursement of $195.00
(in addition to money
owed)
56. Can consolidate IBR 3
different fact patterns to
consolidate different dates
of services, different
injured workers and more
Before we finish, it is
important to note that the
above and what is to
follow, seems complicated,
this is true for the simple
reason that at the start of
2013 most did not apply SB
863 in total, Providers and
insurance alike , so now we
have 4 years of decisions ,
IBR and IMR and WCAB,
and Medical-legal, that are
built on, added to the
foundation created by SB
863. Therefore, now, four
years are added to what was
simple at the start 2013 and
if a foundation was not had
at the start of 2013, it now
appears more complex than
it is.
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The progression that
Provider issues from 2013
to 2017 is as follows: at the
start of 2013 a billing code
or a service or treatment
could have been written on
half a page. Now based on
IBR, IMR, Medical-Legal
decisions and WCAB
decisions , each billing
code a 20-30 page book can
be written based on
objections and payment and
common mistakes. Based
on IMR decisions for a
service, product or
treatment a 30-40 page
book could be written on
each one to show when
applies and as to medical-
legal now in 2017 a 300
page book can be written
based on IBR and WCAB
decisions, knowledge in
2017 either makes success
or failure.
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It is not that it cannot be
made simple, it is just an
aversion by most to keep up
with the laws; examples: I
know of adjusters who pay
out millions in settlements
for certain Providers and
services, even though a law
interpreted in 2015 says
they do not have to even
stating the law incorrectly,
nothing to do with SB 863 ,
or I know of Providers who
lose thousands each day for
failure to venture into what
they do not know, or
medical groups losing 10 to
a $100,000.00 a day as they
stubborn refuse to grasp a
simple and more productive
method based on IBR and
IMR decisions and
medical-legal IR decisions
57. Court order resolving
disputed liability issue may
have to go back to IMR or
IBR or 2nd bill review
process where left off with
time limits- This law is

mentioned 3 times under
SB 863, once for 2nd Bill
review request, once for
IBR request and once
adjuster to do a 30 day
retrospective review. What
this means is depending on
wording and action an
adjuster can pay 0 on a
case denied and later
admitted or a Provider can
get its asserted billed
charges in a case denied
later admitted, a odd
succession of laws that
touch the action of all
parties to come up with
either results, that has not
been applied for 4 years
except one or two adjusters
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2017 newsletter provider issues

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