GQ Corner

Q. Can you please tell me what the rules are on paying for lost time for doctor/therapy appointments?

A. Where a claimant loses time from work to go to the doctor, and the time can’t be made up during the week or where the employer doesn’t pay the claimant for her lost time, you owe TIBs (likely at a reduced rate). In an ideal world, the claimant will schedule her appointment outside of work hours, and to the extent that the work schedule allows, they should. But sometimes that simply isn’t possible. If the claimant is working nights and/or weekends, the appointments are probably easy to schedule and not conflict with work. If the claimant’s work schedule is M-F, 9-5pm, it may not be possible to get to the doctor’s appointments or therapy without missing some time from work. If the appointments cause lost time and wages you’ll have to compensate the claimant for that.

Q. I heard that DWC has issued new forms for SIF recovery, but I can’t find them on the DWC website. Are there new forms?

A. DWC has proposed five new forms to help carriers submit requests for reimbursement from the Subsequent Injury Fund. Use of these forms will be voluntary. The forms are designed to help meet filing requirements under 28 Texas Administrative Code §116.11 and are expected to help expedite an insurance carrier’s request for reimbursement by reducing requests from DWC for additional information. The forms are not yet adopted. They are subject to revision at any time. You can review the draft forms here. Upon adoption, the forms will be available on the DWC forms page.

Q. Does DWC ever audit health care providers like it audits carriers and TPAs?

A. The Division has oversight responsibility of all system stakeholders, including injured workers, employers, carriers and TPAs. This also includes health care providers, who are subject to biennial PBO reviews as well as various other audits. For example, the Division announced last month that it will conduct plan-based audits of certain health care providers who referred injured employees for neuromuscular testing between July 1, 2016 and June 30, 2017. Details concerning those audits, including the scope and methodology as well as the selection criteria for the auditees can be found here.