GQ Corner

Q: I have a claimant that is visiting the emergency room repeatedly. He will attend an appointment with his treating doctor, for which he travels 311 miles round trip, then 4 or 5 days later, he’s at the local emergency room.  His dates of going to the ER are as follows 03/06/16, 04/18/16, 05/01/16, 05/05/16, 05/16/16, 05/28/16, 06/15/16. The claimant was without a treating doctor for some time, but in April of 2016, I was able to find claimant a doctor in Austin that would take his case. Claimant wasn’t happy with that doctor since preauthorization for injections was denied.  The claimant then found a new doctor in Fort Worth in May of 2016.

I need advice on whether I can deny the ER bills.

A: A claimant is required to treat by or at the direction of the treating doctor unless the care falls under an exception such as emergency care. The fact that a claimant is treating in the ER does not make the care emergency care. You therefore may be able to deny the ER bills on the basis that the care is not being rendered by or at the direction of the treating doctor. You need to make sure that the care is not emergency care under the definition of an emergency. Your URA should be able to assist in the review of whether the services are emergency care.

Q: Claimant has completed some post-surgery physical therapy, and has been released to light duty for some time. However, he has a new employer that only accepts full duty and he has not returned to work.  He has just learned he has cancer and has had to put the completion of his treatment for the workers’ compensation injury on hold indefinitely. 

I have requested designated doctor evaluation for MMI and ability to return to work, but is there any way to suspend TIBS because there is a non-work related issue that is delaying resolution either via full duty work release or MMI?

A: To prevail on a dispute of disability, the Carrier would have to overcome the argument that the compensable injury is still “a” producing cause” of the disability.  Without a full duty release or some showing that the disability from the compensable injury has stopped, a hearing officer is unlikely to agree the compensable injury is not at least “a” cause of the disability.