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55% of medical bill reviews overturned: Report

Posted On: Apr. 10, 2019 12:56 PM CST

California

More than half of the requested independent bill reviews in California’s first five years of implementing the new process for reviewing treatments for injured were overturned, according to a report released Tuesday by the California Department of Industrial Relations.

The report draws on data from the state’s Independent Bill Review Organization, put in place with the state’s 2013 implementation of S.B. 863, which revamped the state’s comp system to include independent medical bill reviews aimed at resolving billing disputes for medical treatment and medical-legal services provided to injured workers. The report covers 9,890 bill-review applications received between 2013 and 2017.

Of the bills reviewed, 55% were overturned and 22% were upheld. The remaining 23% were either withdrawn or ineligible for review, according to the report.

The report also highlighted that 46 % of challenged bills fell under the category of physician services, 17.9% fell under hospital outpatient departments and ambulatory surgical centers, and 12.6% of disputes stemmed from reimbursement rates. The other disputes fell between 0.1% and 6.6% and under such categories as inpatient hospital services and pathology, according to the report.

As for top procedure codes included in disputes, unlisted physical medicine/rehabilitation services received the most with 713 of the 9,890 review applications received falling in that category. Other top codes included “comprehensive medical-legal evaluation with extraordinary circumstances” and “treating physician’s progress report” at 378 and 362, respectively.