Common Bill Review Issues: A Sixty-Second Seminar in Workers’ Compensation Claims Handling

It is truly mind-boggling to learn that over the past four years, over 600,000 DWC targeted audit complaints have been filed by medical providers against bill review companies. Such a volume of disputes makes it difficult for us to decide where to begin today’s blog. Therefore, to keep this blog as a one-minute read, we decided to address only the top 3 fundamental errors committed by each side.

Top 3 Errors Made by Medical Bill Reviewers

1. Independent Bill Review (IBR): Failure to reimburse the $180 filing fee whenever additional payment to the provider is awarded by IBR. Reimbursement of the filing fee is mandatory if IBR awards any additional payment to the provider. Although administrators are paying the additional money awarded to providers, far too many are failing to reimburse the $180 filing fee.
2. Reconsideration: Failure to recognize when a medical provider is requesting “reconsideration” of the EOB notice as opposed to resubmission of an invoice. Often the bill reviewer misinterprets the reconsideration request and responds as if the invoice were being submitted for the first time. Instead of reconsideration, the bill reviewer issues a rejection along with an inappropriate explanation advising the bill was previously reviewed and therefore, is now rejected as a duplicate submission. The EOB is never reviewed for reconsideration.
3. Wrongful Denials: Wrongfully denying payment to a QME for a med/legal examination because the QME is not in the employer’s MPN. An MPN does not apply to QME examinations. The easiest way to correct this problem is for the Medical Bill Reviewer to program their computer to never consider MPN status when an ML billing code is used.

Top 3 Errors Made by Medical Providers

1. Using an Inappropriate Software Program: Workers’ compensation electronic billing requires use of an “X-12-837” software program to enable providers to submit bills, as opposed to a Revenue Cycle Management (RCM) system, used for Medicare and health insurance electronic submissions. The two systems are not compatible. Many providers unsuccessfully attempt to submit workers’ compensation electronic bills using the wrong software program. This is a problem that an IT specialist can quickly fix by just downloading a X-12-837 software program.
2. Supporting Documentation: Some providers submit bills electronically but then either fax or mail supporting documentation because they do not know how to attach documents to electronic billing. Providers need to use a “275 file” when submitting supporting documentation with electronic billing. Again, speak to your IT department to correct this problem because separating the bill from its supporting documentation is a recipe for non-payment.
3. Supplemental Fee When Interpreters Are Present: Many medical-legal providers fail to add a comment in the examination report advising that an interpreter participated in the examination. In addition, they fail to provide a very brief explanation as to why an interpreter was necessary. For ML 102 and 103 examinations a “-93 modifier” is used for interpreter services during the examination, which increases the physician’s remuneration by 10%. The rules state that in order to use modifier -93 to obtain the extra 10% fee for an interpreter being present, the examination report “…requires a description of the circumstance and the increased time required for the examination as a result. …” Failure to add this simple explanation forfeits payment of the 10% surcharge.

We urge our readers to share this blog with medical providers and bill reviewers in the hope that going forward, these prevalent errors will be corrected through education, or by minor computer programming adjustments!