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 did IBR begin?
A. IBR became 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. Should I file an application for IBR, a lien with the WCAB, or both?
A. It depends. Please visit Independent Bill Review Versus Lien Filing for a comprehensive discussion.
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 Services 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 $180
- 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.
Prior to Senate Bill (SB) 863, a medical provider engaged in a billing dispute with a claims administrator was limited to filing a lien with the Workers’ Compensation Appeal Board (WCAB) in order to determine entitlement to the amount initially billed. However, SB 863 established a new means of dispute resolution – the Second Bill Review (SBR) and IBR – to expediently decide billing disputes where the only issue is the amount to be paid for the medical service provided. If the medical service is covered by a fee schedule adopted by the Division of Workers’ Compensation (DWC), for example treatment under the Physician Fee Schedule or an evaluation under the Medical-Legal Fee Schedule, or set forth in a contract for reimbursement (Labor Code section 5307.11), then SBR and IBR must be utilized to resolve the dispute within a matter of weeks, as opposed to possible years under the WCAB lien system.
However if a claims administrator has contested liability for the bill for any issue other than the reasonable amount payable for services, then that threshold issue must be resolved before the matter can go to IBR. For example, if there is a liability dispute, such as whether the claim itself or the service is compensable, that dispute must be decided prior to proceeding to IBR and the time for making a request for IBR is extended until the resolution of the dispute is final. Thus there is a tolling of the statute if liability is contested, until that issue is resolved. A provider has 30 days from the date of the resolution of the contested issue or the date of service of a WCAB order finding in favor of compensation to make the request for IBR (Labor Code section 4603.6(a) and California Code of Regulations, title 8, section 9792.5.7(c)(4) and (5)).
By contrast, the limitations period to file a lien is much different. For services provided on or after July 1, 2013, a provider who wishes to protect a claim by filing a lien must file it within 18 months of the date of service, or is foreclosed from enforcing the lien (Labor Code section 4903.5). Currently, unlike with IBR, there is no corresponding provision tolling the statute of limitations if there is a liability dispute or threshold issue which requires resolution. This inflexible statute of limitations for filing a lien, as opposed to an IBR application, creates an ambiguity as to which dispute resolution path should be followed if a liability dispute might extend past the 18-month time limit for filing a lien (Labor Code section 4903.5).
The dual track IBR and lien processes and the differing statutes of limitations means that a service provider may be at risk of missing a statute of limitations and the ability to collect for the service. Hence the question: Should a medical provider in a billing dispute with a claims administrator file an application for IBR, file a lien with the WCAB, or file both?
To answer this question, providers need to ask themselves two preliminary questions:
- Is compensability for the underlying claim disputed by the claims administrator – that is, is there a dispute beyond just the amount payable for service as to whether the injury or specific treatment is compensable as a worker’s compensation injury?
- Is the medical treatment service covered under a DWC fee schedule or reimbursement contract and therefore eligible for IBR? The Official Medical Fee Schedule (OMFS) covers most services clearly identified as “medical treatment”. However, some procedures, especially newer ones, may not be identified as covered services. It may also be unclear whether OMFS definition of a specific medical procedure includes the particular service provided.
Depending on the answers to these two questions, the medical treatment provider should proceed as follows:
- If there is admitted liability for the injury and body part being treated, and the medical treatment is described in the OMFS or a contract for reimbursement, the medical provider should file for IBR if there is a dispute as to the amount owed under the OMFS or contract. Filing a lien in such situations is unnecessary and overloads the system with erroneous filings.
- If there is admitted liability for the injury and body part being treated, but the medical treatment is not described in the OMFS, and there is no contract for reimbursement, the medical provider should file a lien within 18 months of the date of service. If the medical service provided is not covered under a fee schedule adopted by the DWC, and there is no contract for reimbursement, then the matter is not eligible for IBR and the provider’s only recourse is to file a lien. There is no need to file for IBR because the body part is not covered under compensable services listed in the OMFS that can be paid through IBR.
- If there is no admission of liability for the injury or body part being treated, or it cannot be determined with certainty that the medical treatment is covered under a DWC fee schedule or a contract for reimbursement, the provider should file both a timely lien and IBR request, eliminating the risk of running afoul of the lien statute of limitations, and protecting the provider until all these issues are decided.
While filing both a lien and IBR application eliminates the risk of violating the statute of limitations for lien filing, it does require the provider to pay two filing fees: $150 for the lien (Labor Code section 4903.05), and $180 for IBR.
If the provider prevails in the dispute in the IBR forum, the filing fee is recoverable. If it is determined the application is ineligible for IBR, the provider is entitled to a refund of $132.50. Unlike the IBR fee, the lien filing fee is only recoverable if the provider meets the conditions of Labor Code section 4903.07 (i.e., making a timely and complete written settlement demand prior to filing the lien, defendant failing to timely accept, and a final award in the provider’s favor in an amount equal to or in excess of the settlement demand.)
Finally, irrespective of the legal avenues available to resolve disputes, both medical providers and claims administrators should remember that workers’ compensation policy requires good faith negotiations to expeditiously resolve disputes without pre-conditions such as proof of lien filing or lien payment.
Each situation is different and it is always the best practice to contact a legal professional to address your specific circumstances.