Comprehensive Guide to Medical Billing and Payment Rules in California Workers' Compensation

Efficient and compliant medical billing is crucial in California's Workers' Compensation system. One of the key sections addressing this is §9792.5.3, which outlines the rules for medical treatment bill payments. This blog will delve into the essentials of these rules, helping healthcare providers navigate the complexities of billing and ensuring they receive timely and accurate payments.

Overview of Medical Billing and Payment Rules

Purpose of §9792.5.3

Section 9792.5.3 of the California Code of Regulations provides comprehensive guidelines on how medical treatment bills should be processed and paid within the Workers' Compensation system. These rules ensure that healthcare providers are compensated fairly and promptly for their services, thereby maintaining the integrity and efficiency of the system.

Key Billing and Payment Rules

Timely Payment of Bills:

Payment Deadlines: Insurers are required to pay or contest a medical bill within 45 working days of receipt. This timeframe ensures that providers are not left waiting indefinitely for compensation.

Penalty & Interest on Late Payments: If payment is delayed beyond the 45-day period, the insurer must pay penalty & interest at the same rate as judgments in civil actions.

Complete and Accurate Billing:

• Required Documentation: Bills must be complete and accurately filled out using standardized forms, such as the CMS 1500 for professional services or the UB-04 for institutional services. Proper coding and detailed documentation of services rendered are essential to avoid delays.
• Electronic Billing: Providers are encouraged to use electronic billing methods to streamline the submission process and reduce the likelihood of errors.

Dispute Resolution:

• Second Bill Review: If a bill is contested or partially paid, the provider can request a second bill review within 90 days. This request must be submitted using the standardized form specified in §9792.5.6.
• Independent Bill Review: Should the second bill review not resolve the dispute, the provider can request an independent bill review (IBR) within 30 days of receiving the second review decision. The IBR process is managed by an Independent Bill Review Organization (IBRO), ensuring an impartial resolution.

Best Practices for Compliance

Accurate Documentation:

Maintaining detailed and accurate records is critical. Ensure that all medical services are thoroughly documented and that all required information is included in the billing forms. This includes patient information, service dates, procedure codes, and provider details.

Timely Submissions:

Adhere strictly to submission deadlines for both initial bills and any required follow-up documentation. Prompt submissions help expedite the payment process and reduce the risk of disputes.

Utilize Electronic Billing:

Implement electronic billing systems to improve efficiency and reduce errors. Electronic submissions are processed faster and are less likely to encounter issues compared to paper submissions.

Clear Communication:

Maintain open communication with insurance carriers to address any questions or issues that arise during the billing process. Clear and prompt communication can help resolve potential disputes quickly.

Stay Informed:

Regularly review updates to the California Code of Regulations and stay informed about changes in billing and payment rules. This ensures ongoing compliance and helps avoid potential issues with bill submissions.

Interested in Partnering with Medrina Technology Management?

Medrina Technology Management specializes in providing top-tier billing and compliance support services for workers' compensation treating providers. Our team understands the complexities of the Workers' Compensation system and ensures that medical providers meet all compliance requirements. By handling all aspects of billing, payment, and dispute resolution, we allow healthcare providers to focus on delivering exceptional care to their patients. If you're interested in partnering with Medrina for efficient and reliable billing and compliance services, please contact us.

For more detailed information, visit the Division of Workers' Compensation and review the California Code of Regulations, Title 8.