The Role of OMFS in Workers’ Compensation Billing

California’s Official Medical Fee Schedule (OMFS) governs how medical providers are reimbursed for treating injured workers. It sets maximum allowable fees for procedures, evaluations, and other services. While intended to streamline payment and reduce disputes, OMFS can become a barrier when claims are underpaid or denied, and the system doesn’t make it easy to recover those funds.

Medical providers must comply with strict submission and appeal timelines. One of the most critical rules is the 90-day deadline for filing a Second Bill Review (SBR). This deadline is non-negotiable. If a provider fails to submit an SBR within 90 calendar days of receiving an Explanation of Review (EOR), the payment stands, even if it was clearly incorrect.

This hard stop is where many providers lose revenue. Not because their treatment wasn’t necessary, or the documentation wasn’t sufficient, but because the appeal wasn’t filed on time.

When One Missed Deadline Costs Thousands

Earlier this year, an orthopedic clinic in Southern California submitted a bill for a med-legal report under CPT code 99456. The OMFS allowable for this report was $1,295, based on the 2024 California OMFS Physician Fee Schedule. However, the claims administrator reimbursed just $550, citing an “adjusted network rate.” No documentation was provided to justify the discount, and the provider was not a contracted member of the referenced network.

The clinic, overwhelmed by a backlog of billing and a recent staff change, didn’t catch the underpayment until day 104. When they filed the SBR, it was immediately rejected. Not for lack of documentation or coding issues, but solely because it was past the 90-day mark. The appeal was legally invalid.

This single claim resulted in a loss of $745, and it wasn’t an isolated incident. An internal review revealed more than 30 other claims in similar status, underpaid, but outside the appeal window. The total loss: over $22,000 in unrecoverable payments.

How MLM Recovered Revenue and Restored Process

Frustrated and losing trust in the billing process, the clinic reached out to Medical Lien Management (MLM). After a full review of the provider’s billing and collections workflow, the gaps were immediately clear: inconsistent tracking of EORs, no internal flagging system for appeal deadlines, and no escalation process when payers failed to comply.

MLM stepped in with a structured recovery plan. The team first audited all EORs received within the last 90 days, identifying 38 claims still eligible for SBR. Detailed appeals were filed on each, complete with documentation, coding validation, and rationale based on the OMFS. On 12 of those cases, when SBRs were denied without merit, MLM filed Independent Bill Review (IBR) requests through Maximus, the state-contracted IBR provider (California Labor Code §4603.6).

In parallel, MLM coders conducted a CPT and modifier audit across the clinic’s high-volume codes, correcting submission errors and strengthening documentation. Every qualifying case was submitted through Jet Filing, providing time-stamped, verifiable proof of delivery to the Division of Workers’ Compensation. For claims where payers continued to ignore IBR outcomes, MLM escalated the matter by filing Declarations of Readiness (DOR) and taking it to the Workers’ Compensation Appeals Board (WCAB).

Within eight weeks, the clinic recovered more than $41,000 in underpayments. More importantly, they put a system in place, through MLM, to make sure these losses don’t happen again.

Why the 90-Day Rule Is Final

California Labor Code §4603.2(e)(2) and CCR §9792.5.5 are clear: providers have 90 calendar days from the date of receipt of the EOR to submit a Second Bill Review. After that, the payment becomes final and cannot be contested, regardless of errors, coding disputes, or missing documentation from the payer. There are no extensions and no appeal pathways after the deadline passes.

This deadline applies to all workers’ compensation medical billing disputes in California and is strictly enforced.

What MLM Does Differently

MLM was built to address these very issues. With over 30 years of experience in workers’ compensation collections, the MLM team understands how payers delay, how deadlines are used against providers, and how strict enforcement of process leads to results.

Every EOR is tracked. Every appeal deadline is flagged. SBRs are submitted proactively, often within the first 10 days of receiving a response. If underpaid, we don’t chase with emails, we file. We initiate IBRs when denials are unlawful. And when that fails, we litigate.

MLM also uses its proprietary Jet Filing technology to submit documents directly through the DWC’s Electronic Adjudication Management System (EAMS), ensuring timestamped proof of submission and eliminating the payer’s most common excuse: “We didn’t receive it.”

We don’t wait. We don’t rely on verbal promises. We document everything, and we follow the law to the letter.

Protect Your Revenue Before Time Runs Out

Missing an SBR deadline means more than a delayed payment. It means you lose your legal right to recover that money, forever. According to 2023 DWC audit data, over $18 million in underpayments were identified statewide, much of it unrecovered due to missed appeal windows or improper filing (Source: CA DWC Audit Unit 2023 Report).

Most providers aren’t set up to track timelines, handle SBRs, prepare IBRs, and pursue WCAB litigation. But MLM is.

If you’re seeing unexplained reductions, stalled payments, or claims that just sit unresolved, it’s time to bring in a team that works with urgency and precision.

Let MLM monitor your EORs, manage your timelines, and protect your payments, before the system shuts you out.Contact Medical Lien Management
No missed deadlines. No lost revenue. Just results.