Secondary Bill Review versus lien filing (California)

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Secondary Bill Review versus lien filing (California)

Postby spreare on Wed Nov 08, 2017 11:46 am

I feel like I am getting the run around with one carrier's bill review in particular. I bill for auth services, and I get zero paid with EOR boiler explanations. I submit an SBA form, and get same bacl, with nothing really intelligible that I can appeal. How do I know if I can just file a lien versus required to submit to IBR? If services are paid at zero, and EOR says "denied" and I have an auth form for procedures, can I just file a lien?
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Re: Secondary Bill Review versus lien filing (California)

Postby LawAdvocate on Wed Nov 08, 2017 6:36 pm

If your dates of service are after 1/1/13 and the dispute is related to the price - you file an IBR.

If the dispute and the reasons for not payment were the services were not authorized, you weren't in the MPN, etc., you file a lien.

Depending on the basis of the EOR explanations you may in fact need to file both an IBR and a lien.

Since you didn't list the reasons listed on the bill review it is impossible to give you a definitive answer. I am guessing since it was a zero pay, it is a lien issue. If something was paid, it is usually an IBR issue. You have to give more facts as to the exact EOR explanations, they may not make sense to you but they will make sense to many here.
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Re: Secondary Bill Review versus lien filing (California) (Calif

Postby spreare on Wed Nov 08, 2017 9:06 pm

I get EORS that have generic explanations like "resubmit with necessary documentation." "The submitted bill is not supported by the documentation." So then I attache full report, chart notes and copy of authorization with an SBR form and I get the same exact EOR again and zero pmt. Problem is carriers can hide reasons not to pay behind generic and vague explanations. Should I pay the money for IBR, or file lien? But if the pmt is zero, and the EOR is bc the documentation does not support the billing, and we attach the charts, is this something that IBR can even deal with? Can IBR determine what documebtaion is needed to support a billing
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Re: Secondary Bill Review versus lien filing (California)

Postby LawAdvocate on Thu Nov 09, 2017 9:43 am

If you have an authorization - you are in an IBR situation - once authorized the bill must be paid. I know it is as frustrating as hell to try to get a hold of the adjuster and ask them to look at your packet, but and however you may wish to try this.

What I suspect and what I have seen is that documents occasionally get separated in the scanning process - that yours appears to have been separated twice is a systemic issue for that insurance company or a third party administrator. So if you can get any further up the food chain with this particular company, I recommend letting them know your documentation appears to have been separated from the bill and to assure to instruct their scanners to cease and desist. But I know getting to the person who can effect that change is equivalent to getting a private audience with the Pope.

So bottom line, this is not currently a lien issue, this is an IBR issue - however if after you evidence to IBR that the services were in fact authorized and they deny your rights to proceed through IBR (slim and none chance, but I have seen stranger things), then you may have to file a lien.

Good luck.
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Re: Secondary Bill Review versus lien filing (California)

Postby spreare on Thu Nov 09, 2017 11:07 am

What would constitute rights to proceed to IBR or denial thereof? When we submit an Second bill review form and we dont get the results we want, is it up to the provider to initiate the IBR process? For IMR, that process is initited by carrier when the UR is denied it gets sent to IMR without provider having to initiate the process, at east that is what I have seem. I have seen these IMR decisions that I never started but that UR seemed to send up the chain.
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Re: Secondary Bill Review versus lien filing (California)

Postby LawAdvocate on Thu Nov 09, 2017 2:00 pm

Once a provider gets a second bill review they believe to be incorrect, the provider is the one who triggers the IBR process. The carrier would have no clue if you were dissatisfied or not.

You as the provider submit the required IBR forms and documentation along with your check. If IBR finds you are entitled to one cent, the insurance carrier/third party administrator then owes you the IBR fee.

IMR is not triggered or processed by the insurance carrier/third party administrator. UR does not send anything up the chain. The Applicant or the Applicant attorney triggers the IMR process and fills out the IMR forms.

The UR decision and second bill appeal response are the end of the insurance carrier/third party responding. The aggrieved party (the Applicant or the provider) is then responsible for the appeal of either which is the IMR or IBR process. Basic tenet of law - the aggrieved party is always responsible for the next step, otherwise the decision (in this instance the UR or SBR) stands.

There are very specific time frames, forms and documents to submit, so not to be presumptive but after almost five years of this process, I am not sure why you or your billing staff has not been to a training session as to the SBR and IBR processes and requirements?

This is how you get paid.
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