When a claims administrator denies a Second Review for billed services wrongly citing a compensable injury as non-compensable, 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 fill out the DWC Audit Referral form.
Request for Second Review (SBR)
Compensable injury denied as non-compensable.
Additional Complaint Information:
Medical-Legal Second Review for billed services incorrectly denied. Claims administrator denied services wrongly citing injury as non-compensable.
How to file an Audit Complaint
When a claims administrator incorrectly denies your request for Second Review you should:
- Contact Claims Administrator
- Inform claims administrator that your request for Second Review was complete and compliant and included the required supporting documents.
- Alert the claims administrator that you intend to file an Audit Complaint to report the misprocessing of your request for Second Review.
- File Audit Complaint
- Create Audit Complaint:
- From Bill History, choose Denial Incorrect: Compensable injury denied as non-compensable.
- 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): Provide any explanation of review (EOR) received incorrectly citing injury as non-compensable. It is not necessary to include the bill or medical reports.
- Either request an IBR or file a Lien (Required for additional payment)
- File application for Independent Bill Review (IBR) within thirty days of receipt of the explanation of review (EOR).
- File a lien. For more information about lien declaration, see this article.
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.