GQ Corner

Q. The claimant sustained a compensable injury to his low back. He initially indicated that he received prior treatment but later denied this completely. He also refuses to sign a medical authorization or release to facilitate the gathering of his records. Can I obtain them somehow nonetheless?
 
A. You may file a pre-hearing subpoena to pursue the records, but this requires knowledge of the relevant provider or providers with whom the claimant treated. We often send interrogatories in an attempt to elicit this information during the dispute resolution process, but this is also contingent on truthful responses. Beyond this, you may perform a provider “sweep” to confirm the identity of any providers with whom the claimant has treated. Finally, be sure to check the records already in your possession for any such references.

Q. Do I need to file a PLN-11 disputing disability when it is undisputed that the claimant is earning his full pre-injury wages?
 
A. No, there is no need to do so under these circumstances in which there is no claim of disability.

Q. What are the factors considered in Performance-Based Oversight (PBO) to determine in what tier the carrier is placed and how are those factors weighted?
 
A.
• Timely payment of initial Temporary Income Benefits by the insurance carrier – 40% weight
• Timely processing of initial medical bills by the insurance carrier – 30% weight
• Timely processing of request for reconsideration medical bills by the insurance carrier – 10% weight
• Timely submission of Initial Payment data via Electronic Data Interchange (EDI) – 10% weight
• Timely submission of Medical Bill Processing data via EDI – 10% weight
 
Note: You may access online content related to PBO on the Division website at http://www.tdi.texas.gov/wc/pbo/pbo.html.