When a claims administrator remits no response to an Original Bill and supporting documents, we strongly recommend that you file an Audit Complaint. Doing so could improve California workers’ comp billing for the entire community.
Frequently Asked Questions
Q: What’s an Audit Complaint?
A: Audit Complaints are designed to alert the DWC to non-compliant behavior on the part of a claims administrator. Using your Audit Complaints, the DWC can intervene and correct a claims administrator’s improper bill processes.
Q: Will a claims administrator know if I file an Audit Complaint against them?
A: Not if you don’t want them to. The DWC allows you to file Audit Complaints confidentially, so reporting improper behavior poses no risk to your relationship with the claims administrator.
Q: Will filing an audit complaint guarantee correct reimbursement?
A: Not necessarily – the DWC cannot promise that every complaint will result in an audit or investigation. The DWC does intervene when appropriate, though, and the data collected from an Audit Complaint can ultimately lead to improvements across the entire California workers’ comp community.
Reason for Audit Complaint
Use this section to help you fill out the DWC Audit Referral form.
No response to Original Bill.
Additional Complaint Information - Non-electronic Submission (Fax):
To date, no response received from claims administrator for an Original bill and Supporting Documents submitted via facsimile. As documented in the Bill History, the fax transmission is confirmed as received. See rules and regulations cited below.
Additional Complaint Information - Electronic Submission:
To date, no response received from claims administrator for an Original Bill and Supporting Documents submitted electronically. As documented in the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Original Bill and Supporting Documents. See rules and regulations cited below.
How to file an Audit Complaint
When a claims administrator incorrectly processes your Original Bill you should:
- Contact Claims Administrator (Optional)
- Inform claims administrator that your Original Bill was complete and compliant, and included the required supporting documents.
- Explain to the claims administrator that you have verifiable proof the claims administrator received the Original Bill with supporting documents.
- File Audit Complaint
- Create Audit Complaint:
- From Bill History, choose Overdue Processing: No response to Original Bill.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
- Additional Comments: Provide details of conversations and emails with claims administrator, if any.
- Additional Audit Complaint Document(s): None
- Submit a Duplicate Bill
- Per Labor Code 4622: 10% penalty and 7% accrued interest due from the date of receipt of the Original Bill.
Regulations and Rules
Labor Code 4603.3. (a)
Upon payment, adjustment, or denial of a complete or incomplete itemization of medical services, an employer shall provide an explanation of review in the manner prescribed by the administrative director that shall include all of the following:
(1) A statement of the items or procedures billed and the amounts requested by the provider to be paid.
(2) The amount paid.
(3) The basis for any adjustment, change, or denial of the item or procedure billed.
(4) The additional information required to make a decision for an incomplete itemization.
(5) If a denial of payment is for some reason other than a fee dispute, the reason for the denial.
(6) Information on whom to contact on behalf of the employer if a dispute arises over the payment of the billing. The explanation of review shall inform the medical provider of the time limit to raise any objection regarding the items or procedures paid or disputed and how to obtain an independent review of the medical bill pursuant to Section 4603.6.
Labor Code 4622.
All medical-legal expenses for which the employer is liable shall, upon receipt by the employer of all reports and documents required by the administrative director incident to the services, be paid to whom the funds and expenses are due, as follows: (a) (1) Except as provided in subdivision (b), within 60 days after receipt by the employer of each separate, written billing and report, and if payment is not made within this period, that portion of the billed sum then unreasonably unpaid shall be increased by 10 percent, together with interest thereon at the rate of 7 percent per annum retroactive to the date of receipt of the bill and report by the employer. If the employer, within the 60-day period, contests the reasonableness and necessity for incurring the fees, services, and expenses using the explanation of review required by Section 4603.3, payment shall be made within 20 days of the service of an order of the appeals board or the administrative director pursuant to Section 4603.6 directing payment.
The DWC Newsline No. 03-12 January 13, 2012 states: "The Division of Workers’ Compensations has received complaints from qualified medical evaluators (QMEs) that bills are being rejected by claims administrators because they are not on the standardized forms. By statute, medical providers are required to bill using standardized paper billing forms effective Oct. 15, 2011. This is a new requirement for medical treatment bills only. It does not apply to medical-legal bills.
However, the requirement to use the standardized paper billing forms does not apply to medical-legal billings, such as those performed in panel QME or other official QME or agreed medical evaluator, (AME) cases. Therefore, it is not appropriate to reject or object to a medical-legal bill because it was not submitted on a standardized form."
Accordingly, it is not appropriate to reject or object or not timely process a medical-legal bill because it was submitted on a standardized form via electronic billing.
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