Source: https://boehm-associates.com/when-should-a-provider-or-lien-claimant-report-misconduct-to-the-audit-unit/
Timestamp: 2018-01-20 14:47:20
Document Index: 533465349

Matched Legal Cases: ['§ 10109', '§10109', '§5813', '§ 5814', '§ 4603', '§ 4603', '§ 4603']

When Should a Provider or Lien Claimant Report Misconduct to the Audit Unit?
“Insurers, self-insured employers and third-party administrators shall deal fairly and in good faith with all claimants, including lien claimants.” (Labor Code § 10109(e)) Good faith can be defined as honesty or a sincere intention to deal fairly with others.
As an advocate and representative of lien claimants for almost forty years, Boehm & Associates can proudly say that the majority of defendants, attorneys, claims adjusters and examiners we encounter abide by the standard promulgated in Labor Code §10109(e). However, what about the few that regularly do not act in good faith and engage in unfair business practices? For litigated cases, a lien claimant may file a Petition for Labor Code §5813 Sanctions for bad-faith actions and tactics or for a Labor Code § 5814 penalty for unreasonable delay or refusal of payment of compensation, but what about the cases in which no Application for Adjudication has been filed and the Workers’ Compensation Appeals Board has no jurisdiction?
Boehm & Associates has recently begun reporting adjusters and compensation carriers to the Audit Unit of the Division of Workers’ Compensation for violations of Labor Code § 4603.2 and 4603.3 for the following reasons:
Failing to abide by the statutory timelines in issuing EORs. (Labor Code § 4603.2)
Failing to issue EORs in response to initial billing
Failing to issue EORs in response to Provider’s Request for Second Review
Providing EORs that are not in the proper manner prescribed by the Administrative Director. (Labor Code § 4603.3(a))
In addition to filing a Complaint with the Audit Unit, we have provided a copy of the Complaint to the offending adjuster and the adjuster’s supervisor. The immediate changes in attitude and surge of attention our billing issues have received have been refreshing. The instances in which we reported adjusters were for particularly egregious violations. We encourage other medical providers and lien representatives to report adjusters and carriers for the above behavior to discourage further misconduct.