GQ Corner

Q: I received a DWC-26 medical bill reimbursement request from a group health care provider. I owe the reimbursement, but do I need to send it to our workers’ compensation auditing department so they can audit the bill per the workers’ compensation fee guidelines?

A: Texas Labor Code Section 409.0091(h) requires the workers’ compensation carrier to reimburse the lesser of the actual amount paid or the amount payable under any applicable fee guideline. In the absence of an applicable fee guideline, the amount actually paid by the health carrier must be considered in determining a fair a reasonable amount of reimbursement.  The answer is therefore yes, you do have the right to have the bills audited, and you are not automatically required to simply reimburse the amount paid by the health carrier. 

Q: I have a claimant who was paid TIBs for 3 days. I calculated the amount I owed her by taking the AWW, dividing it by 7 to get a daily TIBs rate, then multiplying by 3 for the days she missed. She filed a complaint with the Division and said I should have divided by 5 instead of 7 since her work week is 5 days to get her daily TIBs rate. Is she correct?

A:  Neither method is correct. We never calculate a daily TIBs rate. The formula is always the weekly TIBs rate based on the AWW minus the post-injury earnings for the entire week, then multiply that number by the applicable 75% or 70%. The week is each 7 day period after benefits begin to accrue.

Q: I’m initiating TIBs on a claim. We have a child support lien notice that states $394.63 is owed per week towards child support, but his TIBs rate is $358.57. Do we issue the claimant full TIBs or is there a max percentage that can be deducted from his income benefits? If so, what is the max child support deduction?

A: This is controlled by Texas Labor Code Section 408.203 and Texas Family Code Section 158.009. Specifically, the Family Code directs the Carrier to withhold from the claimant’s benefits the amount specified in the order up to a maximum amount of 50% of the weekly benefits if the child support is current.

However, if the child support is arrearage or back owed child support, you can pay up to 100% of benefits until the amount has been fully reimbursed but no more per week than the maximum the order provides. After the accrued arrearage is fully paid, contact the Child Support Division at the number indicated on the notice to determine if a further balance has accrued. If not, resume full payments to worker or resume withholding only for current obligation per terms of the order.

The order of withholding should direct whether the lien is for current or arrearage. If it does not, we should assume that we pay no more than 50% of weekly benefit per week.