How Do You Dispute a Workers Comp Underpayment?

What Counts as a Workers' Comp Underpayment?

It is a payment below the amount the state fee schedule, or a contract that the state allows in place of it, says the bill is worth. In California the regulations define the "amount of payment" in dispute as payment for services that have an adopted fee schedule or a contract for reimbursement rates under Labor Code section 5307.11 (8 CCR 9792.5.4(a)). In Florida, payment to a provider is subject to the medical fee schedule, and fees may not exceed the schedule unless the provider has agreed in writing to identified procedures (section 440.13).

A denial because the carrier says the injury is not work related is a different fight. California states that issues of contested liability must be resolved before independent bill review (9792.5.7(b)). Sort the two before you choose a path. The workers' comp and no-fault billing service page covers the basics of who pays first.

What Do You Check Before Disputing?

How Does the California Dispute Process Work?

California has two steps in order. The first is a second review by the carrier, and the second is independent bill review. You cannot skip to the second.

Two rules catch offices out. A second review may not add new dates of service or new billing codes (9792.5.5(d)). And if the only dispute is the amount and you do not request a second review in time, the bill is deemed satisfied and nobody owes anything further (9792.5.5(e)). An IBR request covers one provider, one injured worker, one carrier and either one date of service and code or one hospital stay, unless disputes are consolidated, and the regulation text sets a fee per request, so check the current form before you file small items.

How Does the Florida Dispute Process Work?

Florida runs through a petition to the state. Under section 440.13(7), a provider who contests a carrier's disallowance or adjustment must petition the Department of Financial Services within 45 days after receiving notice of the disallowance or adjustment.

• Serve a copy of the petition on the carrier and all affected parties by certified mail.
• Attach every document that supports the petition. A petition without them is dismissed.
• The carrier has 30 days after receiving the petition to send its documents. If it does not, it waives all objections.
• The department issues a written determination within 120 days after it receives all the documentation.
• If the department finds an improper disallowance or adjustment, the carrier must reimburse within 30 days.

A carrier that shows a pattern of arbitrarily or unreasonably reducing payments can face repayment, a fine of up to $5,000 per instance and an award of the provider's costs, including a reasonable attorney fee (440.13(7)(f)).

What If the Claim Is in Another State?

Look up the workers' compensation agency's medical dispute rules before the first denial arrives, not after. The step names, the clock and the form differ by state, and some clocks run from the date the carrier serves its response rather than the date you read it. California counts from the date of service of the explanation of review, and presumes five calendar days after the postmark when there is no proof of service. Until you have confirmed the state's process from its agency, treat the shortest deadline you can find as the working deadline.

What Do the Dates and Dollars Look Like?

Send the request well before day 90, with proof of the date it left your office. Whether a $62.40 gap justifies an IBR fee is a business decision. Batch recurring short payments from the same carrier so one pattern is worth the effort.

What Goes in the Dispute Package?

1. The bill as first submitted and proof of the submission date.
2. The explanation of review, with its service date or postmark.
3. Your fee schedule calculation, one line per disputed code, naming the schedule section and edition.
4. The contract page, if a rate agreement applies.
5. A short cover note that states the amount requested and the reason, in the order the explanation lists the reductions.

Keep it factual. The same structure works for a commercial appeal, and the claim appeal letter post shows the wording. The method for spotting short pays across many claims is in finding payer underpayments against your contract.

How Does Nucleus Align Handle Workers' Comp Underpayments?

Workers' comp and no-fault billing is one of our services, and we work denials within 48 hours. Urgent care billing clients see these cases most often, especially from employer and occupational visits. More explainers are on the blog, or book a call.