GQ Corner
Q. I have a medical only claim with no lost time, but now the claimant has been prescribed physical therapy. The employer does not want to pay him for his time away from work for the PT and he is on modified duty so I can pay him for his lost time. Does the 7-day waiting period apply and how? Does he have to miss 40 hours from work before lost time begins or do we just pay TPD for any lost time from the start?
A. The first day the claimant loses time from work is the first day of disability, even if it is just 1 hour. If the claimant misses 1 hour of work each day from Monday through Wednesday, that is 3 days of disability. The waiting period would apply, so the claimant’s income benefits would accrue on day 8, and the claimant would get paid for the first week of disability once he gets to day 15.
Q. As I suspect most carriers use pharmacy authorization vendors, I am wondering how this works as far as payment of RX off WC claims. Are carriers allowed to reduce the RX below fee schedule based on the pharmacy vendor’s rates if it is not a network claim? This seems different than a doctor in the network agreeing to a rate below fee schedule as providers are specifically listed in the network, but pharmacy companies seem a little different, but is it?
A. Pharmaceuticals may not be regulated through a certified network. Any pharmaceutical not requiring preauthorization may be reviewed retrospectively for medical necessity and any compounded pharmaceutical, all experimental drugs, all investigational drugs and all drugs not included in the DWC’s Closed Formulary (“N” drugs) require preauthorization.
As to payment, the DWC’s Pharmacy Fee Guideline must be paid, unless the pharmacy and the carrier have a contract with a Pharmacy Benefit Manager (PBM)(or “Pharmacy Processing Agent”). In that case, the PBM pays the pharmacy a discounted amount off the Fee Guideline, and the carrier must reimburse the PBM the amount called for under the Fee Guideline.
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