The New York State Workers’ Compensation Board (Board) is issuing new guidance to payers regarding improper filings of the Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B), which have increasingly become a problem.
Medical treatment is the most prevalent area in which the Board is called upon to a resolve a dispute. While a certain amount of disagreement between a provider and a payer is expected, submissions of C-8.1B forms represent the largest volume of forms filed with the Board, with nearly one million filed in the last year, and increasing at a 20% rate. Many of these legal objections should never have been filed, and when they are, they congest the resolution process at the Board, unduly delaying decisions in cases with proper disputes, and unduly burdening the Board and all affected stakeholders.
To help eliminate this unnecessary congestion and utilize resources as efficiently as possible, the Board is providing the following guidance regarding the submission of C-8.1B forms.
The Board said "Payers are NOT to file Form C-8.1B based on any of the following reasons:"
- When the amount billed for a CPT code exceeds the amount designated by the applicable fee schedule and the payer pays the bill in accordance with the medical fee schedule amount; explanation of benefits (EOB) is sufficient;
- When the payer reduces the amount of the bill to 12, 15, or 18 relative value units for evaluations and modalities in accordance with the applicable medical fee schedule ground rule; EOB is sufficient;
- In response to a duplicate medical bill, including a reconsideration request submitted by a provider for a previously submitted medical bill, where the payer has already filed a C-8.1B form; EOB is sufficient;
- When the payer reduces the amount of the bill pursuant to a contractual agreement with the medical provider (e.g., network or PPO); EOB is sufficient;
- After an Administrative Award has been issued in response to a Request for Decision on Unpaid Medical Bill (Form HP-1.0); instead file the HP-2 form;
- In response to an Order of the Chair or a Notice of Resolution from the Medical Director’s Office resolving a prior authorization request (PAR) in favor of the provider;
- When the case has an approved Section 32 waiver agreement for indemnity and medical benefits and the medical date of service is after the approved agreement; EOB is sufficient.
Similarly, to increase the Board’s processing efficiency, payers MUST follow the guidance below when submitting C-8.1B forms:
- At least one objection reason must be selected in Section C.
- Object on the grounds that the claim is controverted (Section C - box 1), only when the claim is both NOT established and the payer has filed either a FROI or SROI-04.
- Do not object on the basis that the medical bill was submitted untimely (Section C - box 6) unless the medical bill is more than 120 days from the date of service.
- Include the provider’s WCB Authorization # and NPI number in the appropriate fields on the form. Do not enter the provider’s billing company in box 9. Enter either the name of the provider who provided the treatment or the facility name.
- File a FROI transaction simultaneous to the submission of the C-8.1B form if a FROI has not yet been filed in the underlying claim.
- Include the WCB Document ID # on the C-8.1B form if a copy of the bill is already in the Board's file. It is not necessary to attach an additional copy of the bill.
- If the basis for the C-8.1B form is non-compliance with the Workers’ Compensation Board’s New York Medical Treatment Guidelines, in addition to checking the appropriate box (e.g., 2, 13-19), payers are required to set forth the applicable guideline and, ideally, a brief explanation included in box 20 about why the treatment deviated from the guidelines.
- If the request for treatment was denied (box 3), and not subsequently granted by the Board, please attach supporting documentation supplying when the treatment was denied, and the corresponding document ID in the case file.
- If box 12 is utilized, the appropriate CARC/RARC code(s) and the corresponding description(s) should be included. In addition, an explanation should be provided to support the objection which may include supporting evidence and/or reference to a document number already in the case file.
Nothing herein is or should be construed as suggesting that payers are limited in filing objections to medical treatment. However, Workers’ Compensation Law (WCL) §13-a(6)(b) requires that those objections must be reasonable and warranted. In the event that payers continue to file C-8.1B forms in the situations delineated above, payers may be subject to penalties pursuant to WCL §§13-a(6)(b) and/or 114-a(3) where applicable.
Questions?
The Board said in the event "you have questions regarding this guidance, please contact New York State Workers' Compensation Claims Operations at (877) 632-4996 and select Option 5."