GQ Corner
Q. We have a subrogation holiday from a third-party settlement. Claimant had surgery but it was paid for by his group insurance and NOT the money he received from the settlement. Is the Carrier required to include any payments made by Claimant’s personal health insurance with the amount from the settlement? Claimant did not pay for the treatment with the funds from the third party settlement – only the co-pay?
A. The credit that you have from the third party recovery is eroded by the accrual of medical bills that you would otherwise owe but for the existence of the third party settlement. In other words, it is not the claimant spending money on health care that erodes the credit; it is your receipt of bills that erodes the credit.
Although there are no statutes or rules that expressly address this situation, the Division published TWCC Bulletin 2004-02 to address this issue. The Advisory provided that following a third-party resolution in which the carrier has subrogation offset or an “advance” as a result of a third-party’s payment of monies in excess of the carrier’s lien at the time of resolution, the healthcare providers are directed to continue submitting preauthorization requests and medical bills to the carrier and the carrier is directed to continue to process the request and bills even though the carrier will not be paying the medical bills because of the “advance” pursuant to section 417.002.
This directive was prompted by the refusal of some carriers to resume benefits after the claimant had paid unaudited medical bills in amounts exceeding the Medical Fee Guidelines. Carriers had appropriately refused to recognize the full amount of the claimant’s payment inasmuch as the carrier would not have paid the same amount had the bills been submitted to the carrier. Since the carriers had refused to recognize the amount paid by the claimant as satisfaction of the advance or offset, and to avoid confusion over the amount of the offset, the carrier were required to process the bills, audit them, and then refer the audited amount to the claimant to pay to the provider.
Q. If there is no wage information available to calculate the appropriate TIBs rate, is the Carrier required to pay the max rate?
A. Technically, no. See rule 128.2. However, if DWC conducts an IP audit or an IBA audit, they are going to pursue the position that absent a wage statement, the carrier should have paid max TIBs. There is nothing to support it. However, what DWC finds is that in many cases there are no wage statements and the adjuster has not requested one or even if the adjuster has received one, if it is not a complete wage statement, then DWC will expect to see some adjuster notes indicating that the adjuster attempted to obtain a wage statement ( if none has been received ) or attempted to obtain a complete wage statement is one has been received but it is not complete. See rule128.2(e).
Q. A chiropractor requested 12 sessions of therapy, and utilization review approved only 6 sessions. After I pay the bill for the six approved sessions of therapy, what do I do with the remaining 6 bills that the chiropractor has sent me?
A. If the additional sessions of therapy required preauthorization, and if preauthorization was given for a definite amount of treatment, and if the treatment exceeded the preauthorized amount, the bills can be denied.
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