GQ Corner

Q:Employer send the bona fide offer by certified mail on 12/28/15. They have not received confirmation that she received or picked up the letter. She has not called or reported to work. What is my time frame to suspend benefits and file a dispute of further disability?

A:Rule 129.6(g) provides the answer to this question. The carrier can consider the wages that would have been earned under the bona fide offer as post injury earnings on the earlier of the date the claimant rejects the offer or the seventh day after the employer receives the offer.  The employee is deemed to have received the offer five days it was mailed.  In your case, the letter would be deemed received on 1/2/16, and the seventh day would be 1/9/16.

Q:We are currently paying the employee partial TIBs. During the Christmas holiday, the claimant didn’t work the week of Christmas and took vacation days. Are partial TIBs owed for that week?

A:If the claimant voluntarily uses vacation days, then that pay constitutes post-injury earnings. If he receives full pay, then no TIBS would be due. If he only receives partial pay, then partial TIBS would be due. 

Q:Are claimants allowed to choose the physical therapy facilities they attend or must they attend PT at a certain facility that’s in the client’s choice of vendor’s network? If the PT provider does not belong to the HCN, I can deny the bills as unauthorized? What if the UR pre authorized the services?

A:The claimant and his treating doctor have the right to pick the PT facility that the claimant attends.  However, that assumes a few things – that if the claimant is in an HCN, that PT facility is a provider within that HCN. If the claimant travels more than 30 miles to attend PT at that facility, then although he is entitled to pick his provider, the carrier is not liable for mileage reimbursement if there are PT facilities within 30 miles of his residence.

The basis of the denial of the bills would be that the carrier is not liable for treatment provided outside the HCN unless it was an emergency or if the HNC approved a request for treatment outside the HCN or if the claimant does not live in the service area covered by the HCN. Even if the UR preauthorizes the services, that only means it is medically necessary. The services still need to be provided by a provider within the HCN unless there are exceptions as identified above.