Independent Bill Review Run Amok: Tuesdays with ClarityMBR

From our friends at ClarityMBR and Daisy Bill:

Spoiler alert: As the title suggests, IBR is not working.

When the IBR regulations were announced, we were excited. “Finally,” we thought, “providers will have recourse for improperly paid bills!” For years we’ve maintained that the WCAB is not the right venue to request additional reimbursement for incorrectly paid bills.

As the regulations were written, we believed in the IBR process. It seemed fair and encouraged providers to only submit legitimately underpaid bills for review. Additionally, because claims administrators are required to reimburse providers’ filing fee if they owe the provider even a penny, it encourages claims administrators to pay the bill properly the first time.

Today, over 7 months after the regulations went into effect, we can say without doubt that the IBR process is not working for two reasons.

1. The DWC is not determining IBR eligibility in a timely manner.

Though IBRs are submitted to Maximus, the company contracted to process IBRs, they first go to the DWC for eligibility review. The criteria for an eligible IBR is not particularly complicated, therefore this should not be a long process. Unfortunately, the regulations do not specify a timeline for the DWC to review eligibility.

Clarity users reported that IBRs submitted over 60 days ago continue to pend for review at the DWC.

Keep in mind, providers only have 30 days from the date of the EOR to submit an IBR, and every IBR filed requires a $335 filing fee. Providers that aggressively monitor their payments are incurring an extreme expense, but are not getting their IBRs reviewed and processed in a timely manner.

How long should providers expect their IBRs to sit at the DWC? We’ve had providers reach out to Maximus and the DWC. Neither entity has provided an answer. This is a fundamental flaw in the IBR process that needs immediate attention.

Recently, the DWC began posting all IBR decisions on their website. It appears approximately 108 IBRs have been filed and 33 have been determined eligible and forwarded onto Maximus for a determination.

If the DWC can’t keep up with this few IBR filings, what will happen when more providers begin filing IBRs?

2. Maximus is reviewing workers’ comp claims using non workers’ compensation guidelines.

California work comp bills are to be paid as per the Official Medical Fee Schedule (OMFS). Unless specifically adopted, Medicare payment rules do not apply. Maximus has rendered IBR decisions (like this one), based on Medicare policies like CCI edits. Even though the DWC has specifically issued notices indicating Medicare policies like this are not appropriate.

While some sections of the OMFS, like durable medical equipment (DME) and pathology, use the Medicare fee schedule as the base for calculating the amount due, most do not. The Physician Services section, for example, is a proprietary fee schedule specific to California workers’ compensation. Codes have their own descriptions and are not updated annually unless adopted by the administrative director.

Additionally, the OMFS has different billing and reimbursement rules for codes and modifiers. Like modifier 50, which indicates a bilateral procedure. Medicare rules state that appending this modifier to a code results in reimbursement of 150% of the base price for the code. In contrast, the OMFS, states that the code should be billed twice, appending the modifier 50 to the second code for informational purposes only.

This Maximus IBR decision incorrectly includes the definitions from Medicare for codes 93307, 93320, and 99325.

The Medicare description of 93307 is “Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography.”

The OMFS description of 93307 42.4 40/60 is “Echocardiography, transthoracic, real- time with image documentation (2D) with or without M-mode recording; complete.”

Medicare 93320: “Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete.”

OMFS 93320 26.9 40/60: “Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list seperately in addition to codes for echocardiographic imaging 93307, 93308, 93312, 93314, 93315, 93316, 93317, 93350); complete.”

Medicare 93325: “Doppler echocardiography color flow velocity mapping.”

OMFS 93325 17.9 40/60: “Doppler color flow velocity mapping (list separately in addition to code for echocardiography 76825, 76826, 76827, 76828, 93307, 93308, 93312, 93314, 93320, 93321, 93350).”

The description of the codes clearly state they are reimbursable in addition to the other codes billed, yet Maximus incorrectly used Medicare payment rules to determine the provider was not owed more money.

The current fee schedule for California Workers’ Compensation services is vastly different than what is used for Medicare and group health.

Until the reviews are done correctly and IBRs are processed expeditiously, the system will remain broken. 

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