A Medical-Legal Bill Is Late: Separate Payment Additions From Bad-Faith Sanctions

A late medical-legal bill can raise a payment issue and a separate sanctions issue. The first asks what money is due under the billing rules. The second asks whether evidence establishes bad-faith conduct of the kind the sanctions law addresses. Keep the requested remedy and its proof separate before adding a sanctions demand to a collection dispute.

In Ramirez Lara, decision, page 4–7, the provider and carrier agreed to resolve the invoice for $626, including penalties and interest if payment issued within 30 days. The provider then pursued sanctions. The WCAB denied them because the record did not establish the required bad faith. The agreed bill resolution and the later sanctions trial answered different questions.

First identify a medical-legal expense and its payment record

Obtain the report, itemized bill, proof of submission, explanation of review, second-review request and final response. Record receipt and service separately. The relevant date may depend on which step is being evaluated. A bill date alone does not show when the administrator received the required report and documentation.

Labor Code section 4622(a) addresses qualifying medical-legal expenses. Subject to its provisions, payment is due within 60 days after receipt of the separate written billing and report. The portion then unreasonably unpaid carries a 10-percent increase and 7-percent annual interest retroactive to receipt. The statute also addresses contested expenses and exceptions. Show why the particular amount qualifies instead of calculating an addition on every unpaid dollar without that analysis.

Choose the review route for the actual disagreement

Under section 4622(b), an amount dispute can require a second-review request within 90 days of service of the explanation of review, followed by the applicable independent bill review procedure. Subdivision (c) separately addresses denials for reasons other than the fee-schedule amount, including a timely provider objection and the employer’s petition obligations. WCAB Rule 10786 supplies further procedures and consequences.

For example, a dispute about which fee-schedule amount applies differs from a contention that the service does not qualify for payment at all. Mark the stated reason in the actual explanation of review. A sanctions petition should not obscure the separate steps needed to preserve the underlying bill dispute. Section 4622(e)(3) also excludes sections 5800 and 5814 from this medical-legal payment framework; do not import a penalty percentage from a worker’s benefit-payment dispute.

Then identify evidence supporting the sanctions allegation

Rule 10786(i)(1) concerns failures caused by bad-faith actions or tactics. It provides reasonable attorney fees, costs and sanctions under section 5813 and Rule 10421 when its requirements are met, in addition to qualifying payment additions. The necessary connection is between the asserted misconduct and the governing bad-faith standard.

In Ramirez Lara, decision, page 5–7, the panel considered the sanctions rules and Duncan v. Workers’ Comp. Appeals Bd., 166 Cal.App.4th 294, 302 (2008). It treated the two possible response delays as mistakes that could be routine errors, without evidence that they rose to sanctionable bad faith. It did not finally adjudicate every billing-review issue at a trial limited to sanctions.

A useful allegation identifies the obligation, the act, who knew what, the explanation offered and the records supporting the asserted improper purpose or willfulness. Preserve correspondence and inconsistent explanations accurately. Repetition may warrant investigation, but a list of delays still requires analysis of the conduct and reasonable excuses. Calling conduct deliberate does not supply that evidence.

Calculate and request each item separately

Prepare separate entries for unpaid principal, the statutory basis for any addition or interest, and the expenses said to result from misconduct. Identify the legal work and costs actually incurred. Avoid a single total that conceals a disputed principal amount or assumes that winning the bill automatically wins sanctions.

If the bill is settled, retain the exact settlement and its timing conditions. Identify what was resolved and what, if anything, was preserved for determination. The $626 agreement in the case included its own 30-day payment condition; that number and condition should not become a standard settlement formula for another invoice.

Our workers’ compensation practice can review the expense classification, billing sequence and specific misconduct alleged. Bring the complete payment file and any settlement—not just the overdue balance—so the next step addresses the remedy the evidence can support.

Under section 4622(b)(2), failure to request second review within the specified 90-day period can cause the bill to be deemed satisfied. Rule 10786(i)(1) addresses failures involving sections 4622, 4603.3 and 4603.6; its particular findings and prerequisites still matter. Match the EOR, objection and review record to the applicable branch before treating lateness as a sanctions award.

First confirm that the services qualify for the medical-legal payment framework. The panel addressed that threshold under sections 4620–4621 in footnote 2. The invoice resolved by the May 2025 stipulation and the October 2 sanctions-only trial were distinct stages; the stipulated payment did not itself prove sanctionable conduct. Ramirez Lara, decision, pages 5–7 and n.2.