©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Healthcare® California Medical Bill Reviewer Re-Certification Unit 1: Workers Compensation Benefit Program Module 4: Liens

CA Regulations Training – LiensMarch 2010 Overview Hi! In this module, you will learn what liens are and who files them. Then, you will learn how liens are resolved and who is involved in the process. Part I: What Liens Are, and Why They Are Filed Who Files Liens in Workers Compensation Injured Workers Providers The State Part I: What Liens Are, and Why They Are Filed Who Files Liens in Workers Compensation Injured Workers Providers The State Lets start by discussing what liens are, and who can file them...

CA Regulations Training – LiensMarch 2010 Why Are Liens Filed? In most workers compensation claims, the employee and the employer know the injury occurred on the job, and benefits payment occurs without a hitch. Lets take a look… However, in some instances payments are not received as easily. In these situations, a lien may be filed. 1. The insurance carrier pays for treatment as it occurs. 2. The injured worker receives workers compensation benefits while he/she is unable to work.

CA Regulations Training – LiensMarch 2010 What is a Lien? Lien: the legal right to take and hold, or sell the property of another to satisfy an obligation or debt. Many different entities may file a lien against a workers compensation claim. Injured Workers Employers Service Providers The State Insurers Lets take a look…

CA Regulations Training – LiensMarch 2010 Providers Injured Workers Who Files Liens? A provider may file a lien if his patients injury was clearly work- related and the reimbursement for his services was incorrect. An injured worker may file a lien for rehabilitation or compensation for permanent injuries that have not been covered by her assessed benefits.

CA Regulations Training – LiensMarch 2010 Insurance Carriers Employers Who Files Liens? The insurance carrier may file a lien to be reimbursed for payments made for an injury that was found not to be work related. A self-insured employer may file a lien to be reimbursed if the workers compensation claim was found to be fraudulent.

CA Regulations Training – LiensMarch 2010 The State Who Files Liens? The State may file a lien to be reimbursed for a workers disability payments if the worker has been on disability while arguing for workers compensation status, and the case is determined to be a legitimate workers compensation case.

CA Regulations Training – LiensMarch 2010 What is Reimbursed? Depending on the circumstances, liens may be filed against a claim for reimbursement for any of the following: Supplies TreatmentLiving Expenses Permanent Disability

CA Regulations Training – LiensMarch 2010 Lien Filing Process Now that you understand what liens are, you are ready to learn how liens are filed and resolved. Part II: The Process: How a Lien is Filed The Bill Reviewers Role How Liens Are Resolved Negotiation Workers Compensation Appeals Board (WCAB) Part II: The Process: How a Lien is Filed Lets start by discussing how a lien is filed...

CA Regulations Training – LiensMarch 2010 Filing Liens Each entity requesting payment may file a separate lien against the insurance company covering the injured worker.

CA Regulations Training – LiensMarch 2010 How is a Lien Filed? To begin this process, a Notice and Request for Allowance of Lien is filed. This asserts a claim or right against a workers compensation case. The Notice and Request form is filled out and attached to a full statement or itemized bill that supports the lien and justifies the right to reimbursement.

CA Regulations Training – LiensMarch 2010 Who Receives the Forms? When a lien is served on a party, it gives notice to the parties involved that a lien has been filed. These parties may include: Applicant Employer Insurance carrier Respective attorneys or other representatives of record.

CA Regulations Training – LiensMarch 2010 What About All the Bills? Bills from a lien may need to be processed to determine payment recommendation. Bills may: Be adjudicated the same as any other bill. Have very specific payment instructions from the claims adjustor.

CA Regulations Training – LiensMarch 2010 So, Whats Your Role? For bill review personnel, contact with lien situations is chiefly for verification of the reimbursement. Several steps occur when a lien bill is sent in for pricing review or the previous pricing needs to be verified. Lets take a look… Remember, liens are legal documents that are handled by legal experts!

CA Regulations Training – LiensMarch 2010 Account Management Account management notifies the legal department that the bill(s) are being reviewed. Step 1: Account Management

CA Regulations Training – LiensMarch 2010 Pricing Examination The pricing is examined and, if the provider is in the network, the contract discounts are verified. Step 2: Pricing Examination

CA Regulations Training – LiensMarch 2010 Verification A representative signs off on the accuracy of review or suggests changes, and sends the review to the legal counsel for final determinations. Step 3: Verification

CA Regulations Training – LiensMarch 2010 How are Liens Settled? Lets take a look… Negotiation Workers Compensation Review Board (WCAB)

CA Regulations Training – LiensMarch 2010 Negotiation Negotiation: the insurance carrier may negotiate a settlement, based on a compromise agreement stipulated by all of the parties involved. Negotiation

CA Regulations Training – LiensMarch 2010 Workers Compensation Appeals Board Workers Compensation Appeals Board: the WCAB reviews the lien in a hearing to determine the compensability and amount of payment. The judge can issue a Compromise and Release that resolves the case and dictates payment or denial of the liens. Workers Compensation Review Board (WCAB)

CA Regulations Training – LiensMarch 2010 Summary What liens are, and why they are filed. Who files liens. The lien filing process. The bill processor's role. Liens resolved by negotiations. Lien Hearings: Workers Compensation Appeals Board.