As a result of SB863, the workers’ compensation system for reimbursement of medical treatment bills underwent fundamental and extensive change. Independent Bill Review (“IBR”) was established under this legislation as an alternative to workers’ compensation liens for resolution of medical bill disputes where the only issue is the amount owed by the carrier on a provider’s bill.
Pursuant to Title 8, California Code of Regulations Section 9792.5.7, when the only issue is the amount of reimbursement due and payable on a treatment bill, and when the medical treatment provider continues to dispute the amount allowed by the carrier for its treatment bill, even after it has timely and properly requested a second review pursuant to 8 CCR 9892.5.5, the medical provider must seek review under the IBR provisions. Failure of the provider to pursue IBR timely and in compliance with all IBR regulations will result in a waiver of any further claim for payment on its bill.
Additionally, bills that are subject to IBR are not eligible to be pursued under a workers’ compensation lien. If a lien is filed, the provider must certify under penalty of perjury that the lien is not being filed solely because of a dispute subject to the IBR process (8 CCR 10770.5).
Boehm represents medical providers in payment disputes subject to IBR, and has been successful in obtaining IBR awards over and above OMFS rates when the carrier has accessed PPO contracts which allow for greater reimbursements. Under 8 CCR 9792.5.7, the IBR contractor, Maximus Federal Services, is authorized to render determinations regarding the correct reimbursement owed to a provider “under the applicable fee schedule adopted by the Administrative Director, or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11.”
The awards obtained by Boehm under the IBR provisions have been substantial, ranging from $6,000 to over $30,000. All of these awards have been pursuant to contracts which allow for reimbursements greater than the applicable OMFS rate.
Additionally, Boehm has successfully defended the award of additional reimbursement when the defendant appealed the IBR decision to the WCAB pursuant to Labor Code Section 4603(f).
Boehm & Associates provides dedicated and comprehensive representation for its medical provider clients, whether the appropriate remedy is through IBR process or the workers’ compensation lien process. We stand ready to assist provider clients in overcoming the obstacles they may encounter in their quest for a fair and appropriate reimbursement for their services and in maximizing their recoveries.