Answers to frequently asked questions about Independent Bill Review (IBR)
Topics covered in this FAQ include:
Q. What is independent bill review (IBR)?
A. IBR is an efficient, non-judicial process for resolving medical treatment and medical-legal billing disputes where the medical provider disagrees with the amount paid by a claims administrator on a properly documented bill after a second review.
Q. When will IBR begin?
A. IBR is effective Jan. 1, 2013 for all dates of service on or after Jan. 1, 2013.
Q. How does IBR work?
A. Upon referral by the administrative director (AD), the independent bill review organization (IBRO) notifies the parties of the assignment and provide them with an IBR case or identification number.
The IBRO assigns an independent bill reviewer to examine all documents submitted, apply the appropriate fee schedule (i.e., Official Medical Fee Schedule, Medical Legal Fee Schedule, Contract Reimbursement Rates per Labor Code 5307.11), and issue a written determination within 60 days of the assignment to IBR.
If the determination finds any additional amount of money is owed to the provider, the determination shall also order the claims administrator to pay the additional sum owed and reimburse the provider the amount of the filing fee.
The IBR determination is deemed the determination of the AD and it is binding on all parties.
Q. What type of medical bill is eligible for IBR?
A. Any medical service bill where the fee is determined by a fee schedule established by the DWC can be resolved through IBR.
Q. How can I request IBR?
A. IBR cannot be requested until after the claims administrator issues a decision following a timely-requested second review and the medical provider disagrees with the second review decision.
To request IBR, the medical provider must submit an application for IBR either electronically or in hard copy. An application for IBR can be completed and submitted electronically by registering as a user on the Maximus Federal IBR tracking system.
If submitting in hard copy, the following information should be included:
- Completed application for independent bill review
- A check or money order for IBR fee of $250.00
- Any required and/or supporting documentation
Mail the above information to:
DWC - IBR
c/o Maximus Federal Services, Inc.
PO BOX 138006
Sacramento, CA 95813-8006
Q. What happens after I request IBR?
A. Upon receipt of DWC form IBR-1, the AD or designee reviews the request to determine its eligibility for IBR.
If the AD determines the request for IBR is not eligible, either party may appeal that determination by filing a petition with the Workers’ Compensation Appeals Board (WCAB).
Untimely requests, requests made prior to completion of a second review and requests made without payment of the required fee are not eligible for IBR. A request may be ineligible for IBR until resolution of a disputed issue, such as contested liability. If the AD determines a request is not eligible for IBR, the provider will receive partial reimbursement of the fee paid with the request.
However, if the AD determines a request for IBR is eligible, the AD will assign the request to an IBRO to conduct a review and issue a determination.
Q. Can two or more disputes be combined into one request for IBR?
A. Yes. At the time a request for IBR is filed a provider may also request the consolidation of separate requests for IBR.
The request for consolidation must specify each dispute for which aggregation is being requested, along with a description of how the requests involve common issues of law and fact or delivery of similar of related services.
The explanation given by the provider must meet the following criteria:
- Aggregation: Two or more requests by a single provider may be aggregated if the AD or IBRO determines that the requests involve common issues of law and fact or the delivery of similar or related services.
- Consolidation for service dates: Requests for IBR by a single provider involving multiple dates of medical treatment services may be consolidated as one request if the requests involve one employee, one claims administrator and one billing code.
The total amount of the dispute cannot exceed $4,000.00.
- Consolidation for billing codes: Requests for IBR by a single provider involving multiple billing codes may be consolidated as one request if the requests involve one employee, one claims administrator and one date of medical treatment service.
- Consolidation upon good cause showing: Requests for IBR by a single provider showing a possible pattern and practice of underpayment by a claims administrator for specific billing codes may be consolidated as one request where there are multiple employees and multiple dates of service but one claims administrator and one billing code.
THe IBRO may disaggregate a request into separate requests and in the event of disaggregation, the provider must pay the required fee for each request.
Q. Can a request for IBR be withdrawn?
A. Yes. If a joint written request for withdrawal is made by the provider and claims administrator before a determination on the amount of payment owed is made, the request for IBR can be withdrawn.
If a request for IBR is withdrawn, the provider is not entitled to reimbursement of the required fee.
Q. Can the IBR determination be appealed?
A. Yes. A provider or claims administrator may appeal a final IBR determination issued by Maximus or a decision by the Acting Administrative Director that an IBR application is not eligible for review. An appeal of either decision must be filed with the local district office of the Workers’ Compensation Appeals Board (WCAB) no later than 20 days after service of the determination. In addition to other WCAB requirements, the “Petition Appealing Administrative Director's Independent Bill Review Determination” must be served on the DWC’s IBR Unit. The petition will not be placed on the calendar and adjudicated by a Workers’ Compensation Administrative Law Judge unless a declaration of readiness is filed.