In the complex world of workers’ compensation billing, medical providers often face frustrating delays and denials from insurance companies and third-party administrators (TPAs). Many of these objections are not only time-consuming but also unfounded. Knowing how to identify and counter these invalid objections is essential for protecting your revenue and reducing the administrative burden on your practice.
Here are 5 common invalid objections insurers use—and how you can successfully navigate them.
1. The Treatment Exceeded the 24-Visit Cap:
This is a common tactic, especially in California workers’ comp cases. Insurers often cite Labor Code Section 4604.5, which limits chiropractic, occupational therapy, and physical therapy to 24 visits each, unless medically justified. However, this cap does not apply to medical doctors (MDs) or treatments beyond the scope of those services.
For instance, in the Marquez, Gonzalo vs. Edwin Allen Adams case, a TPA rejected payment by claiming treatment exceeded the 24-visit cap. MLM’s negotiators successfully argued that the cap was irrelevant since the services were rendered by an MD and validated by PR-2 reports. Ultimately, the lien was settled in-house for $30,000 based on Official Medical Fee Schedule (OMFS) values.
How to avoid it:
Ensure PR-2 reports and medical evaluations clearly show treatment necessity and that services are rendered by licensed physicians when applicable. Promptly challenge misapplication of the 24-visit cap.
2. The Treatment Was Non-Certified:
Another frequent denial centers on claims that treatments were non-certified or lacked prior authorization. While pre-authorization is often necessary, insurers sometimes fail to recognize the iterative nature of workers’ comp treatment plans.
A Primary Treating Physician (PTP) may outline an initial treatment plan for 1-2 weeks and adjust based on the patient’s progress. PR-2 reports document these reassessments and justify continuing or altering care. In the same Marquez case, MLM demonstrated that the treatments were medically appropriate and aligned with regulatory guidelines.
How to avoid it:
Maintain thorough documentation, including RFAs (Request for Authorization) and updated PR-2 reports. When possible, secure written approvals and track all communication with payers.
3. We Owe Nothing Due to Ownership Transfer:
In asset purchase or assignment scenarios, insurers may dispute liability, claiming that they owe nothing to the new entity managing the receivables. This occurred in a recent case where Berkshire Hathaway denied payment to Medlegal Services LLC after the company acquired Medlegal Photocopy Services’ assets.
MLM demonstrated that all assets and rights had been legally transferred through a “Notice of Assignment,” properly filed within statutory deadlines. The insurer’s refusal contradicted established legal principles regarding assignment and payment obligations.
How to avoid it:
When acquiring assets, ensure all assignment notices and supporting documents are filed within the required legal timeframe (typically 20 days in California). Provide complete, well-organized documentation to preemptively counter ownership-related objections.
4. Insufficient Documentation:
Insurers often delay or deny claims citing “missing” or “incomplete” documentation, even when all required records have been submitted. This is a stalling tactic aimed at wearing down providers.
In multiple cases handled by MLM, insurers disputed charges despite receiving all RFAs, PR-2 reports, billing statements, and treatment records. MLM’s negotiators consistently overcome this objection by presenting comprehensive documentation, pressing insurers to acknowledge receipt and comply with regulatory timelines.
How to avoid it:
Use certified or tracked delivery methods when submitting documents. Follow up with confirmation emails and maintain detailed records of all submissions and responses.
5. The Injury is Irrelevant or Non-Compensable:
Some insurers attempt to deny liability by disputing the relevance of the injury to the workplace incident, even when treating physicians and Qualified Medical Evaluators (QMEs) have validated the causal link.
For example, Berkshire Hathaway initially dismissed claims related to Medlegal’s inherited receivables by questioning the compensability of certain injuries. However, QME evaluations affirmed that all services were reasonable, necessary, and directly related to workplace injuries.
How to avoid it:
Support claims with thorough medical reports, QME opinions, and legal arguments grounded in California Labor Code. Engage expert negotiators to counter subjective objections.
Final Thoughts
In a landscape marked by increasing claims disputes and regulatory scrutiny, as highlighted by rising global claims inflation (Kennedys Law) and recent regulatory actions (Goodwin), providers must be prepared for insurers’ common objections.
MLM’s team specializes in dismantling invalid insurance defenses through expert negotiation, legal expertise, and documentation management—freeing medical providers to focus on patient care.
Need help navigating difficult insurers? Contact MLM to learn how we can protect your revenue and streamline the negotiation process.
