Steps to Take if a Bill is Ignored
If your medical-legal claim is ignored or denied by the claims administrator, this is your playbook for objections.
This playbook assumes that you have all your proper documentation, including the request for the QME, letter from party/parties, proper reporting, and most importantly proof of service (or proof of electronic submission) showing reporting + billing sent to the parties of record. If this is a litigated case, double check your Proof of Service includes the same addresses as listed on EAMS.
Claims Administrators are required to pay or contest medical-legal bills within 60 days of receiving the report, bill, and proof of service. Failure to comply with this timeframe results in significant financial penalties, including a 10% penalty and a 7% per annum interest charge on the outstanding amount. Note that administrators get +5 days for mailing for addresses inside CA, or (more likely) +10 days for addresses outside CA but still within US.
At 66 days, file a reminder letter saying:
“We sent this on [proof of service date] and have allowed 60 days. We have not received any response from you. Per Labor Code, 10% penalty and 7% interest applies. We are willing to accept 5% penalty and 3.5% interest if our billing is paid in full within the next 20 days. After that date, this offer is withdrawn, and a formal objection will be filed, and the bill will be referred to our attorney’s office for a Medical Legal Reimbursement Petition, including requesting full P&I and attorney fees/costs. We highly suggest you issue payment to avoid further liability.”
If there is no response, at 90 days, generate a formal objection, including updated calculated penalties and interest.
Identifying Invalid Denials by Claims Administrators, it’s critical to recognize the types of denials that are not valid for medical-legal bills:
- Denial of the workers’ compensation claim AOE/COE: Even if the injury or claim is adjudicated as non-compensable or the compensability of the claim was denied by the employer or payor. Some exceptions do apply including jurisdiction and coverage.
- Out-of-network providers: Denial based on the doctor not being in the medical provider network. MPNs are not relevant in QME medical-legal cases. MPN could apply in PTP medical-legal cases, if there is a dispute over proper designation.
- Lack of authorization: Services must be paid for regardless of prior authorization. However they must be reasonable and necessary at the time they are incurred, and must be substantial medical evidence.
- Insufficient documentation: Denial because the report does not indicate that the service was performed – if you have proof of service for report and billing on proper parties of record. You should still re-serve (and list on your SBR and Proof of Service) any of the documentation that is allegedly missing.
Steps to Take if a Bill is Denied
If a medical-legal bill is denied, you have 90 days from the receipt of the Explanation of Review to:
- File a Provider’s Request for Second Bill Review (SBR)
- File an Objection Letter
- If the provider has signed up for the service, a copy of the objection letter and notice of representation (and whatever other letters/notices s/he requests) will be sent to the attorney so they are on notice for the next step.
Defense Duties Responding to an Objection
When an objection is filed, the defendant must:
- Within 60 days of the objection, file a Petition for Determination of Non-IBR Medical-Legal Dispute and a Declaration of Readiness to Proceed to a Mandatory Settlement Conference (MSC). Upon filing of a Declaration of Readiness to Proceed, the medical-legal provider shall be added to the official address record. The court has clarified that the provider may do this as well if defendant does not.
Providers Responsibilities
If these steps are not taken, the provider can resolve the dispute through the WCAB by filing their own Non-IBR Petition, potentially resulting in the full amount billed, penalties, interest, costs, and sanctions. The provider does not have to file a lien or wait for the end of the case for lien issues.
- If there is no response within 60 days, the attorney takes the next step if they have been served a copy of the objection.
- Or the provider can generate a Non-IBR petition from Simplexam. One of the serving options could be e-fling with EAMS to the WCAB.
Alternately, if the SBR is denied and the dispute concerns the payment amount only, the next step is to file for an IBR within 30 days. It’s essential to adhere to all deadlines to preserve your right to payment.
If request for Second Bill Review and/or Objection Letter are not filed within 90 days of receipt of the denial, the QME/AME loses their ability to object and Claims Administrator/employer has no obligation to pay the billing.
For more information on objections and filing petitions, check out our trusted partner: Injury Compensation Law.
Legal Code References