Why providers must file second bill reviews for workers’ compensation

May 28, 2014
Area(s) of Interest: Payor Issues and Reimbursement Workers' Compensation 

This is the first in a two-part series focusing on coding, compliance and documentation issues relating specifically to workers’ compensation billing. This month’s tip comes from Catherine Montgomery, the founder and CEO of DaisyBill, which offers software solutions for workers’ compensation medical billing.

Workers’ compensation has recently seen dramatic changes in regulations governing both provider billing and insurer claims processing. One of the predictable consequences of these changes has been increasing numbers of billing and payment errors by both providers and claims administrators. These payment errors require appeals that, in the context of workers' comp, means timely and compliant second bill reviews (SBR).

Physicians who dispute the amount of payment are instructed to always submit a complete SBR within 90 days, regardless of the details. Zero pay, partial pay, no medical reports, incomplete bill, no authorization attached, invoiced needed – it doesn’t matter – if more money is due, a request for SBR is always required.

There is no downside to SBR submission; whereas not submitting an SBR leaves the provider in the difficult position of having to justify why an SBR was not submitted – in other words, arguing the complexities and details of the SBR rules and regulations. If the provider loses this argument, his or her bill is void. The consequences of not filing an SBR are dire, as a provider has absolutely no other recourse for additional payment – no second-level appeal, no lien filing, no independent bill review.

As for the timing of the SBR, the clock starts ticking as soon as a provider receives an explanation of review (EOR) from the claims administrator. The SBR detailing the disputed payment must be submitted to the claims administrator within 90 days of receipt of an EOR.

In a recent review of data by DaisyBill, a clear pattern has emerged, indicating that a large percentage of bills are being incorrectly paid. The data also clearly shows that providers who submit SBRs show marked improvement in their revenue. Accordingly, it is essential that every provider treating injured workers create a workflow to identify incorrectly paid bills and to submit and track requests for SBR.

Equally important is to keep track of what you sent and when you sent it. An SBR requires meticulous records to prove compliance, as a provider must have proof of having sent a compliant and timely SBR. Workers’ comp regulations state that claims administrators are not obligated to respond to a provider’s incomplete or non-compliant SBR. It is imperative that providers set up systems to make sure that they are not only compliant with SBR timelines and regulations, but that they have evidence and documentation of such compliance. Technology solutions designed for this process can help; otherwise, providers and their staff must be disciplined and exacting about their SBR procedures.

If you treat injured workers, whatever else you do, for the health of your bottom line, submit an SBR each and every time you receive an incorrect payment.


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