GQ Corner

Q: Claimant submitted a mileage request for travel to and from his doctor. He also included the mileage that he drove from one doctor to another, which was 7 miles. Do we owe?

A: Reimbursement is only required when the point of departure is 30 miles or greater. See Rule 134.110(d):

(d) The insurance carrier shall reimburse the injured employee based on the travel rate for state employees on the date travel occurred, using mileage for the shortest reasonable route.
   (1) Travel mileage is measured from the actual point of departure to the health care provider’s location when the point of departure is:
      (A) the employee’s home; or
      (B) the employee’s place of employment.
   (2) If the point of departure is not the employee’s home or place of employment, then travel mileage shall be measured from the health care provider’s location to the nearest of the following locations:
      (A) the employee’s home;
      (B) the place of employment; or
      (C) the actual point of departure.
   (3) Total reimbursable mileage is based on round trip  mileage.
   (4) When an injured employee’s travel expenses reasonably include food and lodging, the insurance carrier shall reimburse for the actual expenses not to exceed the current rate for state employees on the date the expense is incurred.

Q: We have case where the TENS supplier has  billed numerous times for same dates of service. For example, 2/27/12  billed x 13, some dates of service 10 or more times. There is a MFDR Decision issued 11/20/14 that carrier does not owe charges from 8/14/11 through 8/8/12 due to improper codes, timely filing etc. The provider is now billing again. Can we provide our audit company a copy of the MFDR and instruct them not to audit the bill? Are we obligated to generate EOBs for dates of service covered in the MFDR? Are we obligated to generate EOBs after reconsideration decision on any bill?

A: A provider is not supposed to submit a bill after a carrier has taken final action on the bill. They also should not submit a bill after a DWC order, in this case the MFDR decision, is issued.  I would gather all the bills they’ve just submitted and file a complaint against them. The complaint would serve as your response to their latest submission. There is no need to audit the bills as long as these are for the same services during the timeframe that were previously addressed by the MDR decision.