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California cracks down on claims administrators over medical records

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The California Department of Industrial Relations has proposed $8 million in penalties against several third-party administrators and insurers for allegedly failing to provide medical records in a timely manner for independent medical reviews.

The “orders to show cause” were issued by the department's Division of Workers' Compensation in June and August to Broadspire Services Inc., Gallagher Bassett Services Inc., Sedgwick Claims Management Services Inc., Zurich North America, the California State Compensation Insurance Fund, Amtrust North America and the County of Los Angeles, according to filings sent to Business Insurance on Wednesday.

A department spokeswoman said in an emailed statement Wednesday that pre-hearing conferences and evidentiary hearings are being set with each of the companies that were issued fines.

Under California workers comp reforms passed in 2012, injured workers can request independent medical reviews to dispute treatment that was modified or denied under utilization reviews, which are requested by employers and insurers. Insurers and employers pay for independent medical reviews.

Records show that Broadspire was assessed administrative penalties of $3.53 million for allegedly failing to provide medical records for 705 independent medical reviews within 15 calendar days of receiving notice from Reston, Virginia-based Maximus Federal Services Inc., that conducts independent medical reviews. California law says that the state can assess penalties of up to $5,000 for failing to provide timely information for independent reviews.

Gallagher Bassett was issued penalties of $1.21 million for 242 alleged violations, while Zurich was assessed penalties of $1.1 million of 220 alleged violations, according to filings.

Sedgwick was assessed $940,000 for 188 alleged violations, SCIF was assessed $510,000 for 102 alleged violations, and Los Angeles County was assessed $370,000 for 74 alleged violations, according to records. Amtrust was assessed $340,000 for 68 alleged violations.

A SCIF spokeswoman said in an emailed statement Wednesday that an internal review showed SCIF responded in a timely manner in 31 of the cases cited by the California workers comp division, but did not respond or responded late in 71 cases. SCIF has worked to strengthen its regional oversight of independent medical review requests, among other measures, she said.

Spokespeople for Zurich and Broadspire said they are cooperating with the California workers comp division. Other companies that were issued fines could not immediately be reached for comment.