CostFirst, using its knowledge of the law and Labor Code, prevails against lien claimant’s attempt to collect on paid dates of service without following the SBR/IBR process.
One lien was referred to CostFirst through OptiMix™. The lien was for Fremont Surgery Center that was paid according to the client’s reviews. Lien claimant submitted requests for reconsideration and 2nd EORs were timely generated. Lien claimant filed a lien for the outstanding balance instead of timely submitting an IBR request. Defendant argued that the bill was deemed satisfied and the WCAB had no jurisdiction on the issue. A lien trial occurred on 6/30/17 where the WCJ ruled in favor of the lien claimant stating, “That this dispute is not subject to IBR and that the WCAB has jurisdiction to hear the matter”.
CostFirst filed a Petition for Reconsideration against the Finding and Order and Opinion on Decision contending that the matter was subject to IBR.
The Appeals Board granted the Petition for Reconsideration. The Appeals Board concluded that “disputes over the coding of procedures are disputes over the amount payable under the Official Medical Fee Schedule and are subject to IBR” and, therefore, are not within the jurisdiction of the workers’ compensation appeals board. The Board also reiterated Labor Code section 4603.6(a) to show the SBR/IBR process.
The Appeals Board clarified that although Medicare’s NCCI edits have not been formally adopted into the Official Medical Fee Schedule for outpatient procedures, they are a tool used by IBR in correctly reviewing a medical provider’s bill to determine the correct procedure codes and the corresponding payment amounts.
To read up on the Opinion and Decision after Reconsideration click the link below: