Bulletin No. 00-02
May 18, 2000

DWC to Inaugurate Pilot Program for Resolving Medical Bill Disputes

 The Division of Workers' Compensation will conduct a pilot project from July 1 to Sept. 30, 2000 to assess the feasibility of an administrative process for resolving medical billing disputes.   The only two issues that will be addressed in the pilot will be coding and payment for services in accepted cases where the treatment is also accepted.  Issues related to medical necessity or late payments are not included.

Only disputes involving medical services provided in San Bernardino or Contra Costa counties between April 1st and June 30th will be covered in the pilot.  All DWC medical fee schedules will be covered.

Suzanne Honor-Vangerov, supervisor of DWC's Northern California Regional Center, will be the project manager. She will be working closely with Dr. Linda Rudolph, the DWC medical director, and Dr. Susan McKenzie, associate medical director of the Industrial Medical Council.

Parties interested in participating will be required to submit a request for billing dispute resolution on a pilot form currently being developed.  An instruction form will explain the documentation that must accompany each request for resolution, including service on the other party. The forms, when finalized, will be available on the DWC web site or by mail from the Northern California Regional Center.

DWC will log in each request for dispute resolution. If there has been no response from the other party after 14 days, DWC will telephone the party to determine if they received the dispute resolution request, and if they are willing to participate.  Seven days will be allowed for response.

Within 21 days after receipt of response, DWC will issue a recommendation, with notice to both parties.  If any party is aggrieved by the recommendation of the division's bill reviewer, they can notify the other parties in writing within 14 days of receipt. This process does not supplant the right of the aggrieved party to have the case heard by the WCAB.

The pilot project will help DWC understand where problems come from as well as the nature of the problems; see if it is feasible for this sort of process to resolve coding/billing disputes; and see if parties are satisfied with the process after the pilot is completed.   Other important factors to be evaluated include whether cases ultimately go on to the WCAB for resolution and whether the process works well enough to make permanent.

For more information or to receive forms, contact Suzanne Honor-Vangerov at (925) 952-4100.