Anyone have any info on what the donwside is for an Employer/Administrator who does NOT complete a Second Review of a billing within the statutory time frame. i.e., penalties, fees, etc.

I cannot find the code section for that anywhere.

A provider must request a second bill review within 90 days after receiving payment, if not the bill is deemed satisfied and neither the emplyer nor the employee shall be liable for any further payment.
LC 4603.2 (e) (2)

When filing a lien, the claimant must state under penalty of perjury that the lien is not subject to IBR.

At this point in time, I do not think that there is a specific penalty for that situation. However, there is always a chance that the ER/IC's claim file could be audited, and the Audit Unit has a couple of rather general categories of behavior that they can assess penalties on. I do not know if they would, though if it is not a widespread issue.

rjhertzog wrote:Anyone have any info on what the donwside is for an Employer/Administrator who does NOT complete a Second Review of a billing within the statutory time frame. i.e., penalties, fees, etc.

Hi Rjhertzog,

Interesting question. In my view, the "downside" would be the cost to the IC/TPA to have a DA show up at the lien conference and lien trial if the dispute is not resolved at the conference; the cost of the treatment at issue per OMFS; the statutory increase and/or interest on the amount due; and, incurring the expenses to defend against a LC 5813 petition for bad-faith tactics that wasted the scarce time and valuable resources of the WCAB (sanctions), along with the reasonable expenses incurred by the lien claimant to have an attorney or hearing representative appear before the WCAB at the conference and if necessary, trial (costs).

Lien Examiner is correct in that "the lien claimant must state under penalty of perjury that the lien is not subject to IBR," and due to the failure by the IC/TPA to timely conduct a second review within the statutorily mandated time frame, IBR is inapplicable.

Last, as Sue mentioned, the DWC Audit Unit may get involved --- but I would not be concerned about that toothless tiger.

York McGavin

I apologize, I realize now that I missed the actual question.

According to LC 4603.2 (f)
Except as provided in paragraph (4) of subdivision (e), the appeals board shall have jurisdication over disputes arising out of this subdivsion pursuant to Section 5304.

and paragraph (4)
If the provider contests the amound paid, after receipt of the second review, the provider shall request an independent bill review as provided in Section 4603.6.

My take on this is: If the provider requests a second bill review and receives a response that they still disagree with then they "shall request an independent bill review'" BUT if they request a second bill review and IC fails to submit to the bill review company and they receive no response to their request for a second bill review, then they can file a DOR as the WCAB will have jurisdication.

I believe I am stating the same position as York.