Allow us to give fair warning that some readers may find today’s blog to be disturbing. A great deal of needless trouble and frustration is currently occurring due to the inability of a few medical bill review companies to recognize a simple DWC form. Their actions are causing many problems in workers’ compensation, especially for physicians who provide care for injured workers. We are talking about Form SBR-1 (effective 2/2014), entitled “Provider’s Request For Second Bill Review.” This form was developed by the Administrative Director pursuant to authority granted under California Code of Regulations, Title 8, Section 9792.5.6, to be used when medical providers object to the reduction or denial of a billing invoice as described in the Explanation of Review (EOR) notice. The purpose of the SBR-1 form is to initiate the appeal process. Unless this form is timely filed within 90 calendar days of receipt of the EOR, then pursuant to LC §4603.2(e)(2) all billing disputes related to the invoice are considered resolved as a matter of law.
There is no question as to the purpose of this form. It’s an appeal. In fact, the title of the form is self-explanatory, stating, “Provider’s Request For Second Bill Review.” In addition, the form specifically explains: “The Medical Provider signing below seeks reconsideration of the denial and/or adjustment of the billed charges for the medical services or goods, or medical-legal services, provided to the injured employee. Its purpose is clear.
Yet, for some unknown reason, several medical bill review companies act as if they have never seen Form SBR-1. Physicians and other medical providers are absolutely dumbfounded when bill reviewers respond to a request for a second review with a new EOR stating, “Duplicate Submission – Services Previously Reviewed.” This reply indicates that bill reviewer does not understand the provider seeks reconsideration for work previously done. Denying reconsideration because the bill was previously reviewed is not an appropriate response, and yet it occurs with alarming regularity. DWC records reveal that an astounding 22,155 audit complaints are currently on file against just one bill review company for inappropriately raising “duplicate submission” as an excuse for denying reconsideration. Physicians can’t help but wonder if bill reviewers are doing this on purpose.
Per CCR §9792.5.7(c), unless the provider appeals further to Independent Bill Review (IBR) within 30 days, and pays a $180 filing fee, the dispute is once again presumed resolved as a matter of law. For this reason, many medical providers believe bill reviewers deliberately deny reconsideration, and then wait to see if the dispute is further appealed to IBR. Although it may be understandable for bill reviewers to fail to recognize an SBR-1 form once or perhaps twice, it certainly is not realistic to believe they are unable to recognize the same form 22,155 times.
We at Friedman + Bartoumian acknowledge there are many wonderful and ethical bill review companies working on behalf of good and honest claims administrators. But as always, a few bad apples seem to give the industry a black eye. We here at F+B are available to help educate all our clients on the best practices they should employ as to this process, including their bill review departments.
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