GQ Corner

Q. The injured employee had three compensable Lumbar surgeries prior to being incarcerated. After her release, the injured employee asked to continue her treatment, and supplied me with her medical records from the time she was incarcerated. I sent those records to a peer reviewer, who opined that the medical records do not evidence the need for any additional ODG-recommended treatment. As such, I would like to file a denial to dispute all future medical treatment. How do I do this?

A. Based on this information, you may not prospectively deny future medical care without committing a violation. See Section 415.002(a)(21); and Rules 124.2(j)(4) & (j)(6). Instead, you should wait until you receive a bill and then during the retrospective review process, make sure that your URA has a copy of the review performed by the peer reviewer. If the URA concludes that the treatment is not medically necessary, you will dispute the bill and include denial language on your EOB. If the URA disagrees with the peer reviewer, and concludes that the treatment is medically necessary, you must follow the URA’s determination on medical necessity.

Q. The injured employee had a second job at the time of her injury. I included the second employer’s wages as part of the Average Weekly Wage for purposes of Temporary Income Benefits. The injured employee has been certified at MMI with a 5% impairment rating, do I include the second employer’s wages for purposes of the impairment income benefits as well?

A. Yes, the second employer’s wages will be included for purposes of IIBs, just as they were for TIBs. TIBs and IIBs are based upon the AWW, which takes into account scenarios that involve multiple employment. Please remember that you are entitled to reimbursement from the Subsequent Injury Fund for the payments attributable to the second employer’s wages.