Insurance News:

Workers Comp Updates: Sedgwick and Broadspire erroneous denials

by NYSCA Workers' Compensation Committee | 4/18/2016 3:11:57 PM

As many of you are aware the NYSCA Workers' Compensation Committee has been working with Broadspire and Sedgwick after issues were identified with inappropriate denials of Chiropractic Manipulative Therapy rendered within the recommendations of New York's Medical Treatment Guidelines.

Thanks to the blinded/sanitized examples provided by NYSCA members,  the NYSCA Workers' Compensation Committee was able to demonstrate that denials were systemic issues within the claims payment systems of the carriers. The Committee has been in periodic communication with these two entities to advise them of their flawed logic (which they agreed) and to obtain a timeframe for correction. The Committee also provided our members with updates and procedures to ensure your claims were processed correctly. At the NYSCA 2016 Spring Convention, we summarized the issue with the following.

What does this mean for your office?

Broadspire & Sedgwick are aware of the problem and working on a permanent solution.

What should you do if you continue to experience denials?

  1. For now, contact Broadspire and ask for a supervisor (they have been trained) to have your claim reprocessed. 
  2. Please let NYSCA know if you continue to receive denials.  If not resolved, the Committee will ask the Workers' Compensation Board to intervene. 

The NYSCA Workers' Compensation Committee has suggested to these carriers/TPAs methods that would allow them to query their system & proactively correct their payment errors.

Based upon your feedback at the convention (the issue appears to be ongoing), the Committee has reached out to the New York State Workers' Compensation Board Medical Director Elain Sobol-Berger, MD, noting that the problem has not been corrected. They included a notation that this consumes unreimbursed time from chiropractic offices, and that HP1's are most likely being filed, which consumes unnecessary time of the WCB as well. Dr. Sobol-Berger has reviewed the concerns and has forwarded the issue to the WCB Compliance Staff.

We will keep you posted on the development of this issue. We also thank you, our members, for following through, as well as Dr. Sobol-Berger for directing this issue to the appropriate team.

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