GQ Corner
Q. If a non-Healthcare Network provider sends an injured employee to an out-of-network doctor for chronic pain management, and it is pre-authorized, are we obligated to pay for the services?
A. Under Section 1305.006(3). The treating doctor must obtain approval from the network for the out of network referral. If approval for the referral is obtained, payment is required. If not, payment is not required. If the referral is pre-authorized, but not approved, then you can deny payment for lack of approval.
Q. Claimant attended a mandatory meeting at a hotel in one of the conference rooms. After the meeting concluded, Claimant and other co-workers decided to have a meal in the hotel’s restaurant. While at dinner, Claimant tripped and fell, sustaining an injury. Is this compensable.
A. This will be fact-driven issue. If the mandatory meeting was over, and everyone was free to leave and he chose to stay to eat, you could potentially argue the claimant was no longer in the course and scope of his employment. However, if there was any business component to the dinner, as opposed to a purely personal activity, I think the claimant has a better case for showing that he was still in the course and scope of his employment. If the co-workers are continuing to talk business, especially if there is some expectation that everyone remain to talk, that’s going to be difficult for the carrier to prevail. If the group of co-workers were just gathering because they are friends outside of work, then you have a better case.
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