GQ Corner
Q. What law allows a carrier to re-designate TIBS that have been paid to IIBS when the periods overlap?
A. Re-designation of TIBs to IIBs or vice versa is allowed by DWC. There is no statute or rule that prohibits it. When you are re-designating benefits, you may do so without an agreement from the claimant per Rule 126.16(a)(2).
Q. Claimant required surgery for a compensable injury, and the provider secured pre-authorization for a very specific surgery. However, during the course of surgery, the provider had to perform a second procedure in conjunction with the pre-authorized procedure, and now the provider is billing us for both procedures. Since the second procedure was not pre-authorized, do we owe for second procedure?
A. Generally a carrier is not liable for procedures that require pre-authorization and do not receive pre-authorization. However, if during the pre-authorized procedure it is determined that something over and beyond what was pre-authorized is absolutely necessary, then you may owe for that procedure as well. The thought is that the provider should not have to stop the surgery just to obtain pre-authorization.
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