GQ Corner
Q: This is a 2007 Texas claim where the claimant has reached MMI. The claimant later moved to Florida where he treated with a pain management physician and was released from care in December of 2014. The claim remained medically silent for approximately 6 months; however, the claimant has recently requested to resume care and submitted a request to change treating physicians to TDI-DWC. I received the approval from the Division this morning. The approved treating physician, Dr. Kronlage, is requesting a pre-payment in the amount of $3,500 for the initial evaluation/treatment. Is the carrier required to pay this fee as a reasonable and necessary medical expense?
A: Bills from this out of state doctor will be handled in the same manner as an in state doctor’s bills in Texas. You will not make the determination regarding payment. Rather, route the request through the vendor that makes determinations on payment for the carrier. There is, however, no provision that allows for prepayment of medical bills. The medical provider is entitled to only a confirmation of claim coverage and pre-authorization review of medical necessity of treatment under Rule 134.600. All other aspects of medical billing is reviewed retrospectively.
Q: I have an employer that uses Reemployability to place employees on light duty restrictions with local non-profits if their restrictions can’t be accommodated at the store locations. They do a bona fide offer that designates an alternate job site and outlines that the employees will be paid 80% of preinjury wages by the employer. So instead of getting 70% under work comp, the employer pays the employees 80% of AWW to work with a nonprofit agency within their restrictions. Do I suspend TIBS completely or do I pay 70% of the remaining 20% reduction in wages since the employer pays them 80% of their AWW to participate in this program? Is the 80% wages counted as PIE?
A: Claimant is earning less than her pre-injury AWW so she is disabled. You will use her earnings (the 80% of her regular salary the employer is paying her) as PIE when calculating any partial TIBS that may be owed.
FOLIO
