Medical Bill Review, the Official Medical Fee Schedule, and the 60-Day Clock
A claims administrator receives a $4,800 bill from an out-of-network ambulatory surgery center for a knee arthroscopy performed on an accepted claim. The bill lists CPT 29881 and an facility fee, plus a $600 charge for a surgical tray that is not separately billable under the Official Medical Fee Schedule. The bill arrives 45 days after the date of service. The adjuster's bill review vendor flags the tray charge and notes the facility fee exceeds the fee schedule by $900. The provider is not in the carrier's network and did not obtain predesignation. The adjuster must pay, adjust, or object within the statutory timeframe. The claim is otherwise accepted and the surgery was authorized.
1. What is the correct payment and objection timeline, and what happens if the adjuster misses it?
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Under Labor Code 4603.2, the claims administrator must pay, adjust, or object to a complete medical bill within 60 days of receipt. Here the bill arrived on day 45 of the service-to-bill period, so the 60-day review clock runs from receipt, not from the date of service. The adjuster has 60 days from receipt to act. If the adjuster fails to pay, adjust, or object within 60 days, the provider may be entitled to the amount billed plus a penalty, and the adjuster loses the ability to contest the charges. The adjuster should issue payment for the properly billable amounts and an explanation of review (EOR) for the disallowed amounts within the 60-day window. Missing the deadline exposes the carrier to penalties and interest under LC 4603.2 and to the provider's lien rights.
2. How should the adjuster handle the surgical tray charge and the $900 facility fee overage?
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The surgical tray is not separately billable under the Official Medical Fee Schedule; it is included in the facility or procedure payment. The adjuster should disallow the $600 tray charge and issue an EOR explaining that the item is bundled and not separately reimbursable. The $900 facility fee overage should be reduced to the fee schedule amount, with the EOR citing the applicable OMFS section and the calculation. The adjuster should pay the allowed amounts (the CPT 29881 at the fee schedule rate plus the allowed facility fee) and object to the remainder within the 60-day window. The provider's out-of-network status does not entitle it to bill above the fee schedule for a work comp claim; the OMFS applies. The adjuster should keep the EOR specific so the provider can understand and, if it chooses, dispute the reduction through the proper process.
3. The provider disputes the reduction and files a lien. What should the adjuster do, and how does the 45-day billing delay affect the dispute?
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The adjuster should respond to the lien by documenting the EOR, the fee schedule calculation, and the bundling rule for the tray. The 45-day delay in billing does not by itself defeat the provider's right to payment, but the adjuster should check whether the provider missed any contractual or statutory billing deadline; if the bill was timely under the applicable rules, the delay is not a defense. The adjuster should participate in the lien conference, bring the EOR and fee schedule backup, and be prepared to show the reduction was correct. If the reduction was wrong, the adjuster should correct it promptly to avoid penalties. The adjuster should also review whether the surgery was properly authorized and whether the provider obtained authorization, since an unauthorized service may be the provider's responsibility rather than the carrier's.