GQ Corner
Q. UR received a request for a cervical surgery (anterior discectomy with partial corpectomies at C4-C5 and C5-C6 with hardware and an anterior cervical arthrodesis and fusion at C6-C7 with anterior plating). It was reviewed and approved. He had surgery on 4/8/21. The problem is after further review, this was an error in authorization. He had a DD that opined the cervical is not related. Do we have to pay the bills since it was approved by UR and subsequently me over the phone? Are do we have any legal standing to deny the bills as not related?
A. The fact that there is an extent dispute does not mean that the authorization from the URA was erroneous—it just means that while the surgery was medically necessary, we are not liable for it. As long as the DD opinion states that the conditions for which the surgery was performed are not compensable, you do not owe for it. The EOB(s) would deny the bill on the basis of extent of injury. Make sure you have filed a PLN-11 with DWC and the claimant that has raised extent of injury. This must be done either prior to or concurrently with the issuance of the EOB(s).
If a PLN-11 raising an extent of injury dispute was filed prior to the request for preauthorization, then the URA approval letter should have included language that there was an extent of injury dispute. That language is required per Rule 134.600(1)(3).
Q. Claimant has been employed at store since 3/21/2020 and working as a Shift Supervisor on 4/26/2021. Claimant alleges she was working with some totes and from the repetitive lifting, she started to have pain in the back and both shoulders. Claimant sought initial treatment on 5/06/2021 at Urgent Care and was diagnosed with cervical and thoracic strains. Employer states the claimant was working for store in New York and recently moved to Texas. She was trying to transfer, but had not yet been assigned to a permanent store. Claimant worked for only a few days at the store before being sent, along with the Store Manager and another Shift Supervisor, to another store location to help out with “clean up” for one day. While there, the claimant had words with a Shift Supervisor, as well as reportedly with a customer causing the customer to leave the store. The claimant did not mention having sustained any injury. Based on prior text messages the Shift Supervisor provided, the claimant started at the store sometime between 4/11/2021 and 4/25/2021. The employer states the claimant had been confrontational with other employees and the manager on multiple occasions during the short period of time she had worked at the store. After two store managers expressed their concern regarding the claimant’s conduct with the District Leader, the District Leader reached out to the claimant on 4/27/2021, and told her she would not be able to work at either store. The claimant did not report any injury to the District Leader. On 4/28/2021, the claimant reported to another shift supervisor, that she was working with some totes and from the repetitive lifting she started to have pain in the back and both shoulders. The shift supervisor reported the claim to Carrier. The claimant first reportedly sought medical treatment on 5/03/2021 at a local ER, but we do not have any records from that visit. She first sought treatment from Urgent Care on 5/06/2021, but we only have the DWC-73 from that visit – no office notes. Can we deny?
A. There is no true retaliation defense for carriers in comp—instead, you would be trying to assert that the claimant did not have any injury whatsoever and is instead making the whole thing up because she’s mad at her employer. Removing all the conversations with supervisors and coworkers, you’re left with someone who told a supervisor on 4/28/21 that she’d hurt her back and shoulders due to repetitive lifting on 4/26/21. She then sought treatment as early as 5/3/21, but definitely saw a doctor by 5/6/21. This entire case is going to turn on credibility. If you’re asking do you have a reasonable basis to deny, I think the gap, minor thought it may be, between the injuries and reporting, then reporting and treatment is enough on which to base a denial, particularly when paired with the animosity that was bubbling up between the claimant and everyone else she worked with. Whether you’ll win before an ALJ is a complete unknown since it’ll ultimately come down to whether the judge believes the claimant or the employer representatives. If you’re going to deny, be sure to get recorded statements from all of these individual who can attest to the facts you outlined below. I’d also recommend getting the medical records ASAP since what she reported to the doctors when is going to be of critical importance. Finally, you are correct that since the carrier received notice on 4/28, your 15th day is 5/13.
FOLIO
