June 9, 1995
The Division of Workers' Compensation is requesting the assistance of physicians and claims administrators in obtaining information about disputes over billing and reimbursement for medical and medical-legal services so that these problems may be minimized. The information requested will help pinpoint problem areas that may need to be addressed.
Unnecessary disputes over these issues are costly not only to the parties involved but also to DWC. The number of disputes over bills for medical and medical-legal reimbursement in recent years has helped cause backlogs in many DWC offices, forcing all parties to wait longer than they should to obtain hearings and decisions on other issues.
In most cases, the appropriate amount to bill or reimburse should be clear by reference to the fee schedules applicable to these payments -- Official Medical Fee Schedule (for medical treatment of work-related injuries and illnesses) and the Medical-Legal Fee Schedule (for medical-legal evaluations of injuries.) Uncertainty or confusion over proper billing or reimbursement for specific services may indicate a need for clarification in these fee schedules.
There are penalties for particularly egregious practices, such as claims administrators who knowingly, as a business practice, refuse to comply with known, legally indisputable compensation obligations, or physicians who knowingly bill for services not rendered. Evidence of such abusive practices will initiate appropriate action to penalize the perpetrator.
More importantly, however, identifying and addressing the areas of the applicable fee schedules which are causing confusion and uncertainty will help determine whether and how they may be addressed through regulatory changes. To help in this process, DWC has developed a form in which both providers and payers can provide information concerning what they perceive to be inappropriate billing or reimbursement practices.
All of the information requested should be provided, including an analysis of why the billing or reimbursement level is clearly inappropriate in the identified case (i.e., more than "they didn't pay what I billed" or "they billed more than the applicable fee schedule.") The more information provided about the case and how it was handled, the more helpful it will be.
It should be emphasized that this is not a method to assist in the collection of medical or medical-legal bills. Disputes over the proper reimbursement for those services are determined by filing a lien at the WCAB. Information on how to file a lien for reimbursement may be obtained from an Information and Assistance Officer at a local WCAB district office.