Carlo G.A. Cabezon

Global Holdings Quality Guidelines V 2.0 Author: Carlo Gilberto A. Cabezon Revised: 12/19/2016 Global Holdings Quality Guidelines I. Objective: The purpose of the implementation of the quality guidelines is to standardize the line items currently included in the Quality Assurance Call Calibration form. This is to help identify areas of improvement with regards to the collectors’ performance. II. The Qualifying Line Items and their criteria are as follows: Language Accuracy = 5 points This line item measures the collector’s correct usage of the English language as the primary mode of communication with the adjustors, defense attorney’s applicant’s attorney, etc. This is to ensure that language barrier is eliminated paving the way for a smooth and comprehensive conversation.  Grammar = 2 points: Was the collector able to employ proper usage of grammar? - The collector is assessed on the basis of subject verb agreement and proper prepositions.  Pronunciation and Enunciation = 2 points: Was the collector able to exhibit voice clarity and proper intonation subtly hiding the presence of First Language Influence (FLI)? - This line item is included to ensure that the collector’s voice is well modulated, and encourages the collector to speak at an acceptable pace. This line item also encourages the collectors to speak at a neutral accent to effectively conceal first language influence (FLI)  Minimal Usage of Fillers = 1 point: Was the collector able to minimize the use of fillers, (umm, ah, etc.)? - This line item encourages the collectors to limit their use of fillers. Maximum usage of fillers is limited to three (3) Exceeding the threshold would merit a mark down for this line item. Call Personalization = 5 points This line item assesses the collector’s ability to make a connection to whoever they are speaking to. This is geared towards the collector’s conversation with the adjustors. This line item also aims to help the collectors to personalize their conversation, make a connection and make them naturally conversant which is vital in successfully settling/resolve a bill.  Tone of Voice = 2 points: Did the collector had a neutral and professional tone regardless of who he/she is speaking to? (Customer Service Oriented tone is highly discouraged) - This line item aims to assist the collector to have a stern and professional tone that can help the collector set the mood of the conversation. The collector is expected to match the adjuster’s/DA’s/LR’s demeanor to ensure that the collector is in control of the conversation.  Rapport = 2 points: Was the collector able to make a connection and sounded conversant throughout the call? - This line item encourages the collector to make a connection to whomever they are speaking to. This geared towards making a harmonious conversation with an adjustor. This basis in scoring for this line item is if the collector was able to identify the opportunity for establishing rapport especially if the adjustor’s tone at the onset of call is neutral. Please take note that points would be awarded by default if the adjustor’s tone at the onset of the call is confrontational.  Dead Air = 1 point: Was the collector able to keep the gaps of silences at minimum? - This line items gauges the collector’s ability on minimizing their gaps of silences on their conversation. It is highly recommended that the collector take this opportunity to create small talks to fill in for these gaps of silences. The collector is expected not to exceed the 5 second threshold for dead air which is the recognized threshold industry wide. The collector should abide by the hold guidelines. Note: Should the collector feel that dead air is imminent and cannot be avoided; the collector should ask permission to have the speaker on the other line be put on hold and is expected to press the mute/hold button. Comprehension = 30 points This line item is gauged upon the collector’s ability to have a full understanding of the concern, appropriate response, probing relevant questions  Full Understanding = 10 points: Was the collector able to grasp a full understanding of the concern? Did the collector exhibit proper knowledge and knew the nature of the file prior to making an outbound call? Did the collector had the understanding of the repercussions of working on a non-workable file (SOL barred files, DOS after C&Rd, - except for the purpose of moving files which should be documented in the notes) - This line item enforces the collector to gain a full understanding of the issue by reviewing previous notes that were entered in Conexem. Reading thoroughly through the notes provides the collector certain info that can be used in formulating rebuttal statements or strategies when the conversation transitions over to the negotiation phase. Checking and cross referencing certain tabs to specific documents to determine the possible outcomes for working the file is necessary to better prepare the collector on formulating an approach on working the file.  Responds Appropriately = 10 points: Was the collector able to respond appropriately and accordingly with the correct information relevant to the adjustor/defense attorney/etc. inquiry - This line item is included to encourage the collectors to provide an appropriate response to every statement or inquiry that transpires in a conversation. This is an important indicator that the collector is gauged upon the level of their understanding on a specific discussion with the adjustor/defense attorney/etc. Appropriate responses are the key to sound more naturally and more conversant which is highly important during the negotiation phase.  Probing Skills = 10 points: Was the collector able to probe relevant questions in settling the bill. - This line item aims the collector to practice effective questioning and requesting information that would help them gain leverage when negotiating a bill. For CIC Open: - Ask if the claim was initially accepted or denied For CIC Closed: - Ask for the C&R amount or C&R document, if possible For Denied Claims: - Ask for the denial date. If possible, request for the denial letter For Post Termination Claims/Late filing: - Request for the DWC 1 form For files with Partial Payment: - Check if all line items were paid, request for the check number - Date when the check was issued * For Pre Collections – this would be heavily weighed under this line item due to the nature of the process of pre collecting. Pre Collections Process:   Provide Claim # or Social Number Gather the following information o Claim # (if not available) o Adjuster’s Name o Adjuster’s Direct Number or Phone # and Extension Number o Adjuster’s Fax Number o Email Address (if available) Possible Scenarios Closed/archived claim: - The collector should advise the operator/representative that there is an outstanding bill and ask who to contact to resolve/negotiate the bill. The information that needs to be gathered is the same for the normal pre-collections call. Claim is handled by the lien unit: - The collector should gather lien unit information which is similar to getting an adjuster’s information. System Navigation = 30 points: This line item gauges the collector’s ability in navigating the tool and knowing where to look up for the information needed in reviewing the bill.  Detailed Documentation of Notes = Was the collector able to document every detail pertinent to the discussion that had transpired in the conversation? - This line item aims the collector to practice proper and accurate documentation important details that were discussed on the conversation. The collector should also include in the documentation any information that had been uploaded or faxed/ received before or after the call. The following is a list of certain information that should be included in the notes but are not limited to:  Adjusters Information: - Adjusters Name - Phone Number           - Fax Number - Insurance - Email Date of Denial Case Status Date of Injury Date of Service/s ( Offer History Uploading of Documents Basis of Offer Provider (especially when it has multiple providers) Check number; for files that has been partially paid Date when the check was issued Example: 8/30/2016 8:53 AM [Alfonso, G.] - Spoke to Louis via email, offers $2,500. $11K C&R based on post term claim, claim denied 8/27/2013. DOI 2/14/2013. MRIs provided post denial, excessive scans for one DOS of 11/18/2013. Still negotiating further... Waiting for response... George 8/30/2016 8:52am Red font states where source of information came from… 8/30/2016 8:53 AM [Alfonso, G.] - Spoke to Louis via email, offers $2,500 (via email). $11K C&R based on post term claim (C&R comments on page 11) , claim denied 8/27/2013 (top right page of denial letter). DOI 2/14/2013 (in denial letter). MRIs provided post denial (date of MRIs 11/18/2013, claim denied on 8/27/2013), excessive scans for one DOS of 11/18/2013 (18 line items in ledger on one DOS). Still negotiating further.. Waiting for response... George 8/30/2016 8:52am  Tool Usage = Did the collector maximize all his tools to review and search for every information that are essential in settling the bill? Did the collector update all the necessary fields in Conexem to ensure data and information integrity is maintained? Did the collector take advantage of being a Lien of Record and accessed, reviewed and uploaded pertinent documents found in EAMS External? Did the collector also took the time to check in EAMS for information regarding a case for multiple ADJs and alleged BPs? - This line item encourages the collector to use every tool that can be used to gather information relevant to reviewing or settling the bill. The collector is required to review and upload any documents found in EAMS external or acquired via phone or email interactions that can be used as a resource material for working and negotiating the file. Failure to do so would merit a mark down for this line item. The collector is also expected to check any information found in the yellow strip found in the upper portion of Conexem and review previous interactions by backtracking through the notes. For updating the case status found under the Collections tab, the collector needs to update it to following statuses: For accepted claims - Approved For partially accepted claims - Approved For denied claims – Denied  Call Efficiency = Was it evident on the recording that the collector reviewed all pertinent information (previous collector’s notes, history, etc.) prior to making an outbound call? Did the collector maximized all efforts and took advantage of all favorable case facts and rebuttals to attempt in raising the offer of the adjuster/DA/LR? - This line item encourages the collectors to review the history of the case. This line item encourages the collector to use every information that can be used strategically to gain leverage during the negotiation phase. The collector is required to exhaust all case facts, review all documents Product Knowledge = 30 points: This line item gauges the collector’s familiarization of the Worker’s Compensation process. It is expected of the collector to have a considerable amount of familiarity with regards to the frequently used terminologies and strategic positioning of rebuttal statements.  Familiarization of Terminologies = Was the collector able to use and relate to every terminologies that are being used within the Worker's Compensation business? - This line item encourages the collector to ensure a spontaneous conversation with adjuster/defense attorney. This aims to lessen the collector’s call handling time giving the impression that the collector is professional and respects the adjuster’s/defense attorney’s time.  Utilization of Rebuttal Statements = Did the collector used all pertinent and applicable rebuttal statements in resolving the bill? Did the collector observe the negotiation protocol and avoided rushing in settling the file by immediately jumping to the numbers game strategy and skipped all possible loopholes in the adjusters’ arguments that can be used in maximizing the collectible amount? NEGOTIATION PROTOCOL: 1. Initial demand is always 80% 2. Collectors' authority is at 40% 3. Always get the basis of adjuster’s offer if it is lower than the allotted authority (clocked at 40%). (Probe, gather as much case facts as possible and uncover all objections from the adjuster/DA/Lien Representative) 4. Address any objections from the adjuster/DA/Lien Representative. 5. Always ask for a counter offer regardless of objection. 6. Numbers game strategy should always be reserved as a last resort for negotiating once all case facts and objections had been exhausted. It should also be used strategically when case facts are not in the collectors' favor. - This line item encourages the collector to strategically employ appropriate rebuttal statements. The following is a list of prescriptive rebuttal statements to be used for the most common and basic objections: OBJECTIONS AND REBUTTALS (DIAGNOSTIC: MRI) 1. Referring physician / Doctor is out of MPN a. MPNs are intended for selecting treating doctors. Diagnostics are not treatment but are used to validate injury. b. If claim is accepted: MPN does not apply to ancillary services. OR Get copy of MPN notices. c. If claim is denied: MPN does not apply on denied claims. 2. Unauthorized by UR a. We sent a request to UR and never got a response. b. If AME/QME is available: I’d like to submit this for Retrospective UR. c. If claim is denied: UR objected because you denied liability to the claim. Since this is a denied claim, there is a VERY good chance that this will become a med legal scenario due to the fact that there are medical disputes which will be determined upon review of all medical records by an AME or QME. 3. a. Denied by UR by basis of ---. Ask if UR is aware of the PTP’s new treatment plan. 4. Services were not certified by UR. a. Scans were not used for treatment but is part of the med-legal process to decide industrial causation, to determine nature of disability or to devise a treatment plan. 5. a. Why would you scan a body part that was previously scanned? For comparison to determine if the injured worker is being relieved from the effects of an industrial injury. 6. Per the AME/QME, the body parts you scanned were deemed non-industrial injuries. a. The scans were of medical legal cost and were used to determined non-industrial injury. b. If the adjuster insists that the scans were denied from the start: The scans were used to solidify the carrier’s denial of the body parts. 7. This was a cervical spine injury, why was the shoulders scanned also? a. It’s a compensable consequence because the neck and the shoulders are anatomically related. If there is injury to the neck, I’m sure there’s pain radiating to the injured worker’s shoulders. This can be used for ankles and legs, arms and elbows, fingers & wrists, cervical lumbar & thoracic. The MRIs you did were before we had knowledge of the claim, why are you claiming LC 5402. b. The scans were done to determine if the injury was industrial. The injured worker wanted to make sure of it before filing a claim. 8. Your services are self-procured; we denied this claim after discovery. a. The injured worker self-procured to prove AOE/COE. In the end, all the medical reports will be used to determine AOE/COE, let’s get this lien/bill out of the way now, we’re going to have to resolve this one way or another. b. Patient did not receive reasonable treatment/follow-up appointment and was required to cure or relieve the effects of the injury on his own with the new PTP. 9. a. Treatment is outside MPN even during discovery period. Injured worker wanted a physician that has no ties with both parties. 10. This case C&Rd for nuisance value. I’ll offer 10% a. All medical reports were used to determine industrial injury, hence the reason why you were able to settle for a nuisance value. We helped you save money. 11. We don’t negotiate liens before the case and chief settle / It’s not yet Permanent and Stationary (MMI) a. I am prepared to discount the bill to resolve today. b. This is a very small lien; we want to work this out so that we’ll both save on litigation cost and having to show up in a lien conference. c. The bill is small. There is no reason to delay because we’ll eventually settle this when the CIC resolves. d. Let’s avoid many calls and inconvenience of serving documents for a small bill. e. We really like to resolve this lien, we’ve both have this file/patient for a long time and it’ll be great if we can close this out. f. I had a similar case before with the same circumstance, case and chief hasn’t settled, and we were able to come to an agreement. 12. a. b. This was not a medical necessity It was a med-legal necessity to help prove or disprove the validity of the alleged injured body parts. It was necessary to rule out a disputed body part. 13. The case is still in the Discovery Period / Patient is still treating a. All insurance carriers are required to withhold $10,000.00 per claim during discovery. ACOEM guidelines and we are entitled to payment. I believe the PTP followed all 14. I’m not paying for this because it was a Post Termination Claim a. From the documents provided to our facility, he was still an active employee when the injury occurred. b. The employer may have notice of the injury before termination. Are there documents you can send me proving otherwise? 15. a. You did not show up in court. I recently received the minutes of hearing, I didn’t receive anything regarding a court date, is there any way we can settle this over the phone right now to avoid further litigation cost. 16. The CPT code is invalid in California a. I’ll send the corrected bill ASAP. 17. a. File a DOR. Let’s negotiate this prior to filing the DOR, we’d really like to resolve this to avoid litigation cost. 18. a. Denied because it is non-industrial. I understand that it may have not been denied timely. 19. a. The body part is not accepted or part of the claim. The PTP received more complaints from the patient and had to conduct more tests for new and further findings. 20. a. 21. a. Your charges are above fee schedule. The charges are usual and customary for MRIs. You were paid according to fee schedule. There is an outstanding balance and we’re seeking to resolve this for full and final. Can you send me a copy of the denial letter? 22. This is a duplicate of another bill (professional-technical issue) a. Under the OMFs, the technical part of doing the test is separately reimbursable. Our facility is billing for the technical service provided by our MRI. 23. Your scans were after the AME/QME or after the P&S/MMI. a. The PTP is evaluating the injured for an aggravation of the original injury and the MRI results were needed to determine the extent of aggravation. ORT – Objections, Rebuttals and Transitional Phrases: We don’t negotiate liens before the case and chief settle • This is a very small lien; we want to work this out so that we’ll both save on litigation cost and having to show up in a lien conference. • We really like to resolve this lien, we’ve both have this file/patient for a long time and it’ll be great if we can close this out. • I had a similar case before with the same circumstance, case and chief hasn’t settled, and we were able to come to an agreement. It’s not yet Permanent and Stationary (MMI) • We don’t negotiate liens before the case and chief settle • This is a very small lien; we want to work this out so that we’ll both save on litigation cost and having to show up in a lien conference. • We really like to resolve this lien, we’ve both have this file/patient for a long time and it’ll be great if we can close this out. • I had a similar case before with the same circumstance, case and chief hasn’t settled, and we were able to come to an agreement. He treated outside the MPN • Ancillary services under the MPN rules do not require the facility or doctor to be within MPN. Adjuster: Where does it state that? Agent: Nothing in the Labor Code states ancillary service providers must be within the MPN. I believe the MPN only applies to the PTP. • Last rebuttal: • Was the patient provided the MPN doctor’s list? Can you please send over the document that the patient signed that I can show my manager to get authority to settle for less? (Provide fax number) Doctor does not belong in the MPN • Ancillary services under the MPN rules do not require the facility or doctor to be within MPN. Adjuster: Where does it state that? Agent: Nothing in the Labor Code states ancillary service providers must be within the MPN. I believe the MPN only applies to the PTP. • Last rebuttal: • Was the patient provided the MPN doctor’s list? Can you please send over the document that the patient signed that I can show my manager to get authority to settle for less? (Provide fax number) You did not send in a request for authorization • I believe the PTP sent in a request to make an appointment with us, if we did not receive a response in a timely manner we would proceed with the scan. Adjuster: We never received that request. Agent: I believe it was sent several days prior to the scan. Under the rules, neglect or refusal to provide reasonable medical treatment timely means the scan is assumed approved and authorized. Proper request • I believe the PTP sent in a request to make an appointment with us, if we did not receive a response in a timely manner we would proceed with the scan. Adjuster: We never received that request. Agent: I believe it was sent several days prior to the scan. Under the rules, neglect or refusal to provide reasonable medical treatment timely means the scan is assumed approved and authorized. This was not a medical necessity • I believe it was a med-legal necessity to help prove or disprove the validity of the injury. • The PTP deemed the test was medically necessary for the patient’s diagnosis and treatment. This was denied by UR on the basis of XXXX (gather information) REBUTTALS: MULTI - POSITIONAL MRI SCANS First, the treating doctor believed the positional MRIs were medically necessary based on evidence-based guidelines according to AMA Guidelines 5th Edition page 372. Second, we billed you for modifier 27 of a positional MRI pursuant to the 22 modifier of the CPT code for an unusually complex positional MRI, as specifically ordered by the patient's physician. We have billed for more than 1 unit of service. This is appropriate and not duplicative. All three procedures - neutral, flexion, and extension - of the multi-positional MRI are each payable under the OMFS by the use of the "Multiple Procedure" Modifier-51. Third, the positional scans should be paid since the MRI’s were used to evaluate patients in positions that are impossible to assume in a conventional MRI. Which allowed us to perform flexion, extension, lateral bending and rotational studies which when compared to the neutral position, can often expose critical information that leads to a more accurate diagnosis. Lastly, positional scanning allows physicians to evaluate anatomical elements under realistic stress and even scans the subject in the exact position that causes them to experience specific symptoms. NON-MPN DOCTOR, NON-MPN FACILITY, SELF-PROCURED MPNs are ONLY intended for selecting treating doctors and DIAGNOSTICS or MRI’s are not treatment but used to validate whether there is injury or not. Labor Code 4600 So meaning, you agreed that our services should be paid regardless if it's not within the MPN because MRI is considered as an ANCILLARY SERVICE. Diagnostics are not treatment but are used to validate injury. Also, it does not make sense to construe section 4616.6 as a general rule of exclusion, barring any use of medical reports other than those generated by MPN physicians. Section 4616.6 states nothing of sort. If the Legislature intended to exclude all non-MPN reports, the Legislature could have said so; it did not, right? Plus, reports of attending or examining physicians, may be received as evidence under section 5703. OR IF PATIENT is currently living in a rural area, or temporarily working or living outside the MPN service area, or you are a former employee permanently living outside the MPN service area, the MPN or your treating doctor will give you a list of at least 3 physicians who can treat you. The MPN may also allow you to choose your own doctor outside the MPN network. Contact your MPN for assistance in finding a physician or for additional information. (Patient has the RIGHT to go outside MPN to see specialist like Orthopedic, Chiropractic) IF the SPECIALIST is out of MPN, you have the RIGHT to get one outside the network. Patient has the right to disagree to be transferred to an MPN doctor if only the 4 criteria’s are met. MRIs or DIAGNOSTICS NOT MEDICALLY NECESSARY 4604.5 (c) The board held that an applicant is entitled to such medical treatment as is reasonably required to “relieve” from the effects of industrial injury, even if such treatment will not “cure” that injury. OR This diagnostic information will be able to clinically correlate exam findings and subjective complaints to formulate objective opinion regarding patient's overall condition and make an informed decision regarding further care. OR If physiologic evidence indicates tissue insult or nerve impairment, consider discussion w/ a consultant regarding next steps, including selection of an imaging test to define a potential cause (MRI) for neural or other soft tissue, computer tomography for bone structure. And additional studies may be considered to further define problem areas. CERVICAL OR LUMBAR SPINE, NOT MEDICALLY NECESSARY ACOEM 2nd Ed, Chapter 8, Diagnostic and Treatment Consideration, p.178 CT, MRI, demonstrate the HIGHEST degree of specificity to identify ANATOMIC DEFICIT in diagnosis of neck and upper back pathology. POST TERM DENIED During the time the patient was working for that employer he or she did not encounter any symptoms while at work. After the patient left work or got terminated that is the only time the patient encountered problems to whatever body parts and decided to seek medical treatment. Got an attorney and referred him to a doctor. (Of course defense is going to argue post term but that would be the applicant’s fault and not ours.) Patient got referred to us and we can’t deny any patient who walks to our office according to the California Labor Code. Also, it’s not our burden of proof but the Applicant’s attorney. If the claim was denied, (Then follow up REBUTTAL ON NOT AUTHORIZED) REFUSE TO OFFER Adjuster or DA/Hearing Representative/Paralegal MUST provide a GOOD FAITH OFFER Title 8, CA Code of Regulation sec 10109 (e) mandates that “All insurers, self-insured employers and third-party administrators shall deal fairly and in good faith with all claimants, including lien claimants.” BAD FAITH ACTION - Labor Code 5813 (NOTE: Please be careful of using this. We cannot use this as rebuttal at all times. You have to consider some things before saying or emailing this LC. To be sure, ask your supervisor if it’s ok to use this on the file you’re working on) CHECK LIST: - If adjuster is not responding at all (must pre collect first to know who the handling adjuster is or ask assistance from his/her supervisor to resolve our lien/medical bill) - If the offer is too low, unreasonable, no basis and/or no supporting document to back up the very low offer - keeps on promising through phone or fax or email to pay or negotiate, yet not complying 5813. (a) The workers' compensation referee or appeals board may order a party, the party's attorney, or both, to pay any reasonable expenses, including attorney's fees and costs, incurred by another party as a result of bad-faith actions or tactics that are frivolous or solely intended to cause unnecessary delay. In addition, a workers' compensation referee or the appeals board, in its sole discretion, may order additional sanctions not to exceed two thousand five hundred dollars ($2,500) to be transmitted to the General Fund. (b) The determination of sanctions shall be made after written application by the party seeking sanctions or upon the appeal board's own motion. (c) This section shall apply to all applications for adjudication that are filed on or after January 1, 1994. REQUEST FOR DOCUMENT: (IN A FORM OF LETTER) If you are not agreeable to resolving this lien for 75% of our original balance, please be advised that lien claimant demands immediate service of all medical reports, AME, QME and/or PQME, C&R, Stipulation & Request for Awards, F&As, F&Os, Notices, Objections to our billing and denial letter. This demand is made pursuant to California Code of Regulations Section 10608. Please be further advised pursuant to California Code of Regulations Section 10608(e), any reports filed in violation of this section may be discarded by the WCAB at the time of a Lien Trial. Please note that this demand will be used to exclude any documentation that you intend to present as evidence at a Lien Trial in this matter. Refusing to provide AME/QME or med legal documents to non-physician lien claimants. LC 4903.6(D) Petition for order allowing service of medical docs pursuant to LC 4903.6 d Under 5c) Service of Medical reports, Medical-Legal reports and other medical information on a non-physician lien claimant -This means we need to be served documents even if we are not the physician. REVIEW OF MEDICAL RECORDS LC 4622 A: 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 Section4603.6 directing payment. LC 5402 Within one working day after an employee files a claim form, the employer is responsible for the first $10,000.00 in medical treatment regardless of whether they deny the injury thereafter, until the claim is denied or accepted, therefore we are also entitle to LC 5402 money. I know you are aware of that. Also, 5402 does not state that the first $10k is only allowed for MPN doctors. LC 5402 and LC 4603.2 The bill is entitled for $10k reimbursement since the DOS is within the discovery period. Please refer to LC 5402. Also, medical treatments must be paid in 45 days since we didn't receive any objection in writing 30 days after in receipt of our bill. Refer to LC 4603.2 DENIED CLAIM: - When did you deny the claim? What’s the basis of the denial? AFTER OUR DATE OF SVC: - The Denial does NOT apply on this file since this was denied after our DOS.” - REBUTTALS ON 5402 POST TERM / LATE FILING: - It is not our burden of proof but the Applicant’s attorney or the applicant. (Then follow up REBUTTAL ON “POST TERM DENIED” and “NOT AUTHORIZED”) - Patient got referred to us and we can’t deny any patient who walks to our office according to the California Labor Code. - Although a denial has been issued on post-termination (and statute of limitation) bases with respect to this claim, these are neither persuasive nor favored defenses in a continuous trauma claim. .Due to the length of employment, the type of activities and the positive EMG/NCV in the past, I believe it is likely we will face a finding of compensable injury, which requires a finding of industrial causation. The real issue is the cost of treatment in this case. The treatment which includes multiple modalities and medications is extensive and costly. In the event she requires further diagnostics or testing’s or worse, even surgery, I would estimate medical costs exceeding ($35,000.00 to $45,000.00). I have also seen a finding of up to 30% permanent disability for this similar case. BEFORE DATE OF SVC: - Should this went to AME/QME, we’ll have Med-legal, and we’ll eventually get paid, probably more than fee schedule... But as early as now, I can get a lower authority for you to get rid of this file. How much can you do? - (Can you send me a copy of the Denial and DWC1 Form please?) NO SUFFICIENT EVIDENCE TO SUPPORT INDUSTRIAL INJ / NOT MEDICALLY NECESSARY: - (REBUTALL ON “NOT MEDICALLY NECESSARY”) - It was necessary to rule out a disputed B/P and a med-legal necessity to prove or disprove the validity of alleged injured B/P. UR DENIAL: - Check if it’s UNTIMELY DENIED - if it’s AFTER our DOS, Denial is not applicable. - (Check if there’s Retro UR) - Check if it’s TIMELY DENIED - if it’s BEFORE our DOS, use REBUTTAL ON - “NOT AUTHORIZED” - UR objected on our services because you, (the adjuster) denied the claim. Since this is a denied claim, there’s a good chance that this will become a med-legal due to the fact that there are medical disputes w/c will be determined upon review of medical records by an AME or QME. Thus, using or medical records under LC 4622, we will get reimbursement for the services we provided...” - If AME/QME is available - “I would like to re-submit this for Retro UR.” - UR NON CERTIFIED - Scans were not used for treatment but is part of the med-legal process to decide industrial causation, to determine nature of disability or to devise a treatment plan. DENIED BODY PARTS: - Since these are denied b/p, there’s a good chance that this will become a med-legal due to the fact that there are medical disputes w/c will be determined upon review of medical records by an AME or QME. Thus, using or medical records under LC 4622, we will get reimbursement for the services we provided. ACCEPTED CLAIM - I just want to ask since this is an ACCEPTED claim, how come we have not received any payments yet? How much can you do? - Our bills should have gone through the bill review within 90 days upon billing you but since we have not received any payment, I will do 80% to get this resolved for full and final. ACCEPTED CLAIM - NON MPN: - Use rebuttal on “NON-MPN” - Get copy of SIGNED MPN NOTICE ACCEPTED CLAIM - CIC OPEN: - Our bills should have gone through the bill review within 90 days upon billing you but since we have not received any payment, I will do %80 to get this resolved for full and final TODAY to save us both time and money waiting for Lien Con which will happen after a lifetime.. What do you think? Code of Conduct Violations (Auto fail)