California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.04 - Training Required for Medical Bill Reviewers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every insurer shall require all medical
				  bill reviewers, other than those defined in section
				  2592.01(h),
				  including employees and agents of medical billing entities used by the insurer,
				  to be trained. The insurer shall require at least 40 hours of training for
				  medical bill reviewers, at least 30 hours of which shall be conducted in a
				  classroom by an instructor. No more than ten (10) hours of training may be done
				  on the job.
(b) The training
				  required by this section shall be completed within a twelve (12) month period,
				  during which time a medical bill review trainee may review bills under the
				  supervision of an instructor, experienced medical bill reviewer, or experienced
				  claims adjuster. No individual may review medical bills on behalf of one or
				  more insurers for a combined total of more than twelve (12) months unless the
				  individual has been trained pursuant to this article.
(c) Any classes or courses taken within one
				  (1) year before the effective date of these regulations that satisfy the
				  curriculum requirement of subdivision (h) below may be used to meet the hourly
				  requirements upon verification by the student to the insurer or medical billing
				  entity of the type of course taken, the course of study, the date or dates
				  taken, the person or organization providing the class or course, and the number
				  of hours taken.
(d) Upon the
				  effective date of these regulations, every insurer shall require a minimum of
				  16 hours every two (2) years of post-designation training for all medical bill
				  reviewers and shall include in the post-designation training changes in the law
				  affecting medical bill reviewers and topics as specified in subdivision (h)
				  below.
(e) Failure of a medical
				  bill reviewer designated pursuant to subdivisions (a) or (c) of section
				  2592.05 to fulfill the
				  requirements for post-designation training every two years pursuant to
				  subdivision (d) above shall result in that person being no longer considered a
				  designated medical bill reviewer. That person shall not be authorized to review
				  medical bills until the requisite number of hours of post-designation training
				  is completed.
(f) The insurer may
				  provide the designation training directly or by sending its employees or agents
				  to be trained by a training entity for the entire designation curriculum. The
				  insurer shall require all medical billing entities that review or adjust
				  medical billings on its behalf to have the medical billing entities' employees
				  or agents trained directly by the medical billing entity, the insurer, or by a
				  training entity for the entire designation curriculum. The insurer shall
				  certify, in the manner provided for in sections
				  2592.07 and
				  2592.09, that the course of
				  instruction provided or that is provided by its medical billing entities meets
				  all the requirements set forth in this article and that all medical bill
				  reviewers of the insurer and its medical billing entities have actually
				  attended the training for the required number of hours.
(g) A medical bill reviewer who has received
				  a Designation as having completed the training required by this article shall
				  not be required to be re-trained and re-designated in order to review medical
				  bills for a different insurer.
(h)
				  The curriculum for the training of medical bill reviewers shall include, but
				  not be limited to, the following topics:
(1)
				  The correct use of billing codes and detection of improper use of billing
				  codes.
(2) All fee schedules
				  applicable in California to workers' compensation medical care, including
				  statutes and regulations authorizing the fee schedules.
(3) Workers' compensation benefit
				  provisions.
(4) Fraud.
(5) Medical terminology.
(6) Utilization guidelines (American College
				  of Occupational and Environmental Medicine or other guidelines approved by the
				  Administrative Director of the Division of Workers' Compensation.)
(7) Medical evidence.
(8) Liens.
(9) Ethical issues.