GQ Corner

Q: Can a peer review of a medical records review be used to  deny future medical treatment?

A: No. Generally, the carrier cannot prospectively deny future medical treatment. A blanket denial of future treatment will result in an administrative violation. Treatment must be reviewed for medical necessity only as proposed for services subject to preauthorization requirements of Rule 134.600, or retrospectively for other services during the bill review process. However, updated peer reviews may be advantageous to support your position.

Q: If an employer does not report an injury to the carrier for several months and then we receive the first report of injury, do we still have 15 days from the carrier’s date of notice to deny the claim? Or is it waived because the employer did not turn it in in a timely fashion?

A: The employer’s actions can never waive any right that the carrier has. The carrier always has 15 days to investigate the claim before it is liable for accrued benefits. It has a full 60 days to investigate if it is paying benefits up until the date of dispute.

Q: A bona fide job offer was submitted to the claimant. However, he has failed to work the hours outlined in the bona fide offer and thus has not been earning his preinjury wages. Can I dispute future indemnity benefits? 

A: If the post injury earnings claimant has received since the bona fide job offer have been less than average weekly wages, but the bona fide offer was for average weekly wage, you must investigate the reason for the shortfall in wages.  If the reason the claimant worked less hours and thus did not earn his preinjury wage was because the employee did not show up for scheduled work, then you can dispute the amount of TIBs. But if the reason he earned less was because of the failure of the employer to accommodate the restrictions or scheduled the offered hours, then you will owe TIBS based on the difference in the AWW and the actual earned wages.