A lack of clear exceptions to the 12-month submission window in California has created significant challenges for medical providers. With automatic denials becoming the norm, despite valid reasons for late submissions, claims administrators are exploiting a loophole in the absence of defined rules for timely filing exceptions.
In 2016, California State Bill 1160 established new timely filing requirements for workers’ comp medical treatment bills. Labor Code Section 4603.2, effective in 2017, allows claims administrators to deny payment if a bill is not submitted within a year from the date of service. However, the code also directs the Division of Workers’ Compensation (DWC) to adopt rules defining exceptions to the 12-month submission window. Unfortunately, no such rules have been adopted, leaving providers in a precarious situation.
Due to the absence of well-defined exceptions, claims administrators are setting up systems to automatically reject or deny bills that exceed the 12-month deadline. This practice applies even to bills that may qualify for reimbursement and can lead to substantial financial losses for providers. While reasonable exceptions exist, claims administrators prioritize automatic denial to avoid reimbursement obligations, exploiting the lack of clarity surrounding timely filing rules.
There are legitimate scenarios where medical providers may need to submit a bill after the 12-month deadline, such as when a liability dispute is involved. The Labor Code itself mentions liability disputes as an example of exceptions to the timely filing requirement. However, claims administrators often overlook these valid reasons and reject bills solely based on the date of service and submission.
Although most billing disputes qualify for Independent Bill Review (IBR), cases involving compliant bills wrongfully rejected necessitate the less common option of filing a lien.
It is crucial for providers to be aware of their rights and take appropriate action. Efforts should also be made to encourage the adoption of clear rules defining exceptions to the timely filing requirement, ensuring fair and reasonable practices in workers’ compensation billing and reimbursement.
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