The Department of Industrial Relations and its Division of Workers’ Compensation posted a progress report on the department’s Independent Bill Review (IBR) program.
IBR is a process used to resolve billing disputes for medical treatment and medical-legal services provided to injured workers.
Prior to SB 863, a medical provider engaged in a billing dispute with a claims administrator was limited to filing a lien with the Workers’ Compensation Appeal Board in order to determine entitlement to the amount initially billed.
SB 863 established Second Bill Review (SBR) and IBR to decide billing disputes expediently, in which the only issue is the amount to be paid for the medical service provided. If the medical service is covered by a fee schedule, then SBR and IBR must be used to resolve the dispute.
The “2018 Independent Bill Review (IBR) Report: Analysis of 2013-2017” examines the IBR program activity from its implementation, capturing all applicant filings through December 31, 2017, thus providing an evaluation of the program during the first five years following its enactment.
During the first few months of the program, the IBRO received only a handful of applications. In the second quarter, filings increased and then accelerated throughout the remainder of 2013. In 2014, 2,009 applications were filed. The number of filings in 2015 and 2016 was nearly identical: 2,345 in 2015 and 2,385 in 2016. In 2017, filings decreased approximately 10 percent from the peaks in previous years, to 2,151.
In the first five years following IBR’s implementation, almost half the challenged billings (46.2%) related to Physician Services, including visits, consultations, and nonsurgical procedures. The second-highest number of review requests was for services at hospital outpatient departments and ambulatory surgical centers (17.9%). Disputes with contracts for reimbursement rates were the third highest (12.6%).
Among the filings that receive a review and a case determination, 71.1 percent are “overturned,” meaning the IBRO determined that additional reimbursement is warranted. The claims administrator’s determination is reversed, so the provider is due reimbursement for the review cost, along with the amount for review of the billing and fee schedule.
Overturned IBR case decisions for applications filed in 2013-2017 resulted in reimbursement to the providers totaling $12,277,568. This amount includes the repayment of filing fees for those cases. When IBR was introduced, the filing fee was $335. Effective April 1, 2014, this fee was reduced to $250 and then further decreased to $195 on January 1, 2015.
“We hope the findings of this report will encourage health care providers to consider using IBR for some of their payment disputes,” said DWC Administrative Director George Parisotto.
The progress report is posted on the DIR website.