Regarding the lien reqs. (California)

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Regarding the lien reqs. (California)

Postby spreare on Tue Dec 11, 2012 12:21 pm

Can someone please help me out with this.
I mean, starting next year, if provider decides to take a denied case, or denied body part, and carrier will not reimburse provider for whatever reason, then how do we get our money when carrier is not playing ball? I understand the $150 filing fee., but isn't this in addition to the $350 IBR fee that is required to file a lien?
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Re: Regarding the lien reqs. (California)

Postby davidd on Tue Dec 11, 2012 3:07 pm

If the case is denied then all IBR/IMR is deferred until the underlying issue (i.e. AOE/COE or body part liability) is adjudicated. If employer wins, you lose. Period. That's it. No money for nothing but nothing. If employer loses then the next step is UR, then IMR, then IBR. You don't file a lien until you have no further resolution via IBR.

So, again, if employer wins on the denial of the underlying issue, then you lose - i.e. you will have provided services for free. There is absolutely no recovery option ... yet.
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Re: Regarding the lien reqs. (California)

Postby LienExaminer on Tue Dec 11, 2012 4:00 pm

I believe LC5402 (c) would still be applicable ... IC would pay for treatment during the delay period per LC 4600 payble per the applicable fee schedule.
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Re: Regarding the lien reqs. (California)

Postby davidd on Tue Dec 11, 2012 4:09 pm

Great post LienExaminer, and I would generally agree, except that speare was asking about a "denied" case.

5402(c) only deals with a delayed case: "until the date that liability for the claim is accepted or rejected."

But you bring up a bigger issue - enforcement of 5402(c) in a delayed case where treatment IS provided legally, even if the claim is ultimately denied. In those situations, the procedure is UR twice, IBR next, then lien if not satisfied, along with all applicable filing/administration fees to be fronted by the provider and reimbursed upon successful resolution in favor of provider (otherwise lost).
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Re: Regarding the lien reqs. (California) (California)

Postby jonbrissman on Tue Dec 11, 2012 7:24 pm

Hi, David. There is a remedy after the employer prevails on a AOE/COE defense: The provider may bill the patient directly. Recognize that L.C. Sect. 3751(b) prevents a provider from billing a patient while the claim is pending. There is no bar to billing the patient for services provided on a non-industrial injury after the court determined the injury was non-industrial.

Further, Sect. 3751(b) allows the provider to bill the patient directly during the pendency of the claim if the provider has received written notice that liability for the claim has been rejected.

It may not be a great remedy because often the patient is judgment-proof, and sometimes a civil statute of limitations will impede collection efforts; nonetheless, the provider is not without remedy on denied claims.

Civil Code Section 3523: "For every wrong there is a remedy."

JCB
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Re: Regarding the lien reqs. (California)

Postby spreare on Tue Dec 11, 2012 9:43 pm

So in denied cases, or denied tx, provider going to have to pay IBR?
I mean, what if we do not dispute the carrier bill review? Or is it assumed the carrier IBR will be 0 ?
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Re: Regarding the lien reqs. (California) () (California)

Postby sharonc on Tue Dec 11, 2012 10:34 pm

spreare wrote:So in denied cases, or denied tx, provider going to have to pay IBR?
I mean, what if we do not dispute the carrier bill review? Or is it assumed the carrier IBR will be 0 ?


You don't go to bill review until the medical issues are resolved. So, IBR won't even accept the case.
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Re: Regarding the lien reqs. (California)

Postby ozzie on Wed Dec 12, 2012 11:36 am

So basically, it's the end of the tunnel for the gold mine of entitlement in workers' comp.

It has always amazed me that so many lien claimants - and I'm not speaking of reputable providers here - would simply just start treating and sending bills, knowing that down the line they would simply file a lien, battle it out, and walk away rich.

And I do mean RICH, to the tune of $80,000 of chiropractic treament for minor soft tissue injuries that never received any other treatment; for $17,000 plus from one notorious So. Calif multi-specialty clinic for evaluations only - no treatment - on a sprained thumb: first the Chiro, who referred to the Ortho, who referred to the Neuro, who referred to the Psychologist, who referred to the Internal Med and the Psychiatrist, for - of course - initial, supplemental, then final P&S evaluations.

In the real world outside the Comp Dreamland, no doctor, no dentist, no psychiatrist, no "H-Wave" provider, no EMG specialist, not even a sign painter, would ever dream of performing work until the party responsible said "I'd like you to do this," and agreed to pay (and to be clear, there is an implied in law agreement that when I walk into a dentist or whatever, that I will pay for services even though I did not sit down and discuss the contract with the doctor, barber, dentist, whatver.)

Why would a medical provider just assume they could make the employer or insurance company pay? Because the system was grossly flawed, and allowed them to do that. Because they could.

Welcome to the real world, just like everyone else now.
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Re: Regarding the lien reqs. (California)

Postby spreare on Wed Dec 12, 2012 12:43 pm

Ozzie you have always painted with a broad brush. I mean as far as lien filing, its sometimes impossible to get the tx authorized through UR that the AME recommended. But no one can dispute the abuses.
An $80k chiro bill! 24 tx cap was passed in 2003, so not sure how that would happen.
I am not sure the fat lady has sung her last song on this. maybe she has, but maybe there will be challenges and maybe people will figure out how to game the system again. Ozzie, seriously, you think people will not figure out how to game this system, either legally or through illegal means? Even medicare gets gamed to the tune of Billions with DME billing, etc. how is workers comp going to be game safe?
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Re: Regarding the lien reqs. (California)

Postby bvpharmacy on Wed Dec 12, 2012 1:51 pm

Waiting for the Aoe/Coe issue to be tried is great, except as you all know, 90% of the cases settle by C&R. Do you go to bill review on C&R without a Thomas? With a Thomas.
Do the employers/carriers want to try the AOE?COE issue on all of there C&Rs?
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