Choosing Your Battles Wisely under SB 863 Reforms
Wednesday, May 8, 2013 | 0
California's Senate Bill 863 differs from past reforms with clear and unambiguous consequences to medical providers for failure to comply. The provisions of SB 863, relating to payment for medical services may seem obvious and the risks manageable, however, there are aspects of SB 863 yet to be determined which regulations and/or case law are sure to mandate.
These yet to be realized consequences for medical providers are reflected in the several new avenues that have been created by SB 863.
The following is a list of requirements and the supporting regulations that have penal consequences for medical providers in the process of collection of the medical bills for services rendered to injured workers:
- Independent bill review process or lien process: selecting the wrong avenue will result in the file being uncollectable and possible sanctions at the Workers' Compensation Appeals Board.
- Proceeding to hearings at WCAB: You have to prove all elements of the claim; causation, medical necessity, reasonable reimbursement, failure to do so results in dismissal and sanctions.
- Not paying lien activation fees on liens filed prior to 2013 by Dec. 31, 2013: Liens will be dismissed by operation of law (need to start looking at all liens on file at WCAB).
Unknowingly, undermining the IBR process through commitment of issues on request for second review. This is the unforeseen consequence of SB 863: The IBR process in general is not discretionary. If a party requests a second review under the assertion of reasonable reimbursement and the insurance company does not defer the IBR process, the provider must follow the IBR process for that issue and cannot state that they prefer going through the lien process and attempt to bring to the WCAB an IBR issue to bypass the time requirement for IBR and avoid the payment of the $335 fee. This most certainly will be clarified through case law in the near future.
Time to file liens: For dates of service after July 1, 2013, the time to file liens is 18 months from date of service. Accordingly, a collection file has to be developed faster as to causation, medical necessity and reasonable reimbursement. However, because the dates of service are in 2013, the IBR and independent medical review process also applies and one handling the file must not lose sight of that. The issue being, if the collections file is deferred to the lien process based on contested liability issues, when and under what circumstance does the file have to go back to either the IBR or IMR process before that file is considered uncollectable even if the resolution of the contested liability issue is resolved in favor of the medical provider/lien claimant?
As pointed out above, the reforms and their results on medical providers appear to be predictable. SB 863 has clear consequences for non-compliance in every aspect of the process for collections of payment for medical services. There are also consequences for payers as well. Therefore it is incumbent upon all parties to the workers' compensation system to keep an open mind when trying to understand and follow the new reforms created by SB863.
Reid L. Steinfeld is general counsel for Grant & Weber. Richard Boggan is a consultant for the company.
Comments