03/01/00 - FOL



03/01/00

00-01

INTEREST

Rule 126.12....does the insurance carrier owe interest in the following scenario:

Treating doctor certifies MMI as being reached on 10/11/99 with a 10%IR. The TWCC-69 is received by the insurance carrier on 2/1/00 and payment is made on 2/6/00 is the insurance carrier required to pay interest? 03/07/00

No. The intent of the rule and the statute upon which it is based is to require the payment of interest by the insurance carrier when the insurance carrier’s action delays the payment of benefits.

Therefore, interest is only due when a payment is late because of the insurance carrier’s actions. There are two conditions under which Rule 126.12 requires the insurance carrier has to pay interest: 1) when the insurance carrier has refused payment due to a denial of a claim or dispute of entitlement to benefits and the insurance carrier loses the denial/dispute or 2) when the insurance carrier does not timely make the payment.

The delay in payment in this example (10/11 to 2/6) is based upon either a backdated date of MMI or a very late TWCC-69. The insurance carrier received the report on 2/1/00 and timely initiated the payment within 5 days. Therefore, no interest is owed. If the insurance carrier had made the initial payment 2 days late, then the insurance carrier would be required to pay interest on the 2 days the insurance carrier was late.

NOTE: If receipt of the TWCC-69 was due to the late filing by the doctor, a violation should be referred to Compliance & Practices Division.

03/02/00

00-02

RULE 129.2(4)

The question has been raised by injured employees and employers of whether or not the injured employee can use just a portion of their accrued sick leave and accrued annual leave before they can become entitled to TIBs? In other words, if an employee voluntarily uses sick leave or annual leave is the employee required to use all accrued leave?

20000307

The answer depends upon whether the employee is an employee of a public entity (i.e. a state agency, UT, A&M, TxDOT, or another political subdivision) or whether the employee is an employee of a private employer.

Use of sick leave and annual leave by an employee of a public entity is governed by Texas Labor Code Chapters 501 to 505.

Employees of private employers may voluntarily use all or part of their sick leave or annual prior to receiving TIBs.

However it should be noted that the voluntary use of sick leave or annual leave is merely a form of post-injury earnings and that an employee who is receiving sick or annual leave may still be entitled to TIBs based upon the difference between the employee’s AWW and their post-injury earnings.

03/07/00

00-03

SIBs

Does an injured employee, enrolled in school, have to look for work during spring break or summer vacation when those periods fall within the qualifying period of a SIBs quarter?

20000307

The Appeals Panel has held that a claimant who is enrolled and satisfactorily participating in classes sponsored by Texas Rehabilitation Commission or a provider of vocational rehabilitation [defined in rule 130.101(8)] may satisfy the good faith requirement for SIBs under rule 130.102(d)(2). (see APDs 992427, 000001)

However, when the claimant has failed to attend school because of the summer session (which falls within the filing period) the Appeals Panel has upheld decisions against a claimant’s entitlement to SIBs. (See APDs 992564, 992708, 992787).

While there are no cases on point regarding spring break, rule 130.101(8) requires a vocational rehabilitation program to include, in part, a description of the services to be provided or arranged and the start and end dates of the described services. Therefore, if the period of spring break fell within the dates of service of the rehabilitation plan, the claimant would come under rule 130.102(d)(2) Each case should be reviewed on a case by case basis according to 130.101(8) to determine the stipulations of the plan.

04/06/00

00-04

TIBs

Question is from Midland Field Office and the Date of Injury is 10-21-98. Employer has collective bargaining agreement with employees and their union to continue 30% of salary for 13 weeks when employee is out on accident benefits.

In this case the carrier began TIB's and at the same time the employer continued to pay full salary for 4 weeks. The employer now wants to recoup the salary from IIB's. QRL 95-149 says some of these payments may be gratuitous.

Can a carrier recoup payment from IIBs when an employer continued salary "but" employer didn't file TWCC-2 (voluntary payment form).

20000411

No. T.L.C §408.003 provides that after an injury, an employer may: initiate benefit payments, including medical benefits; or supplement income benefits paid by the carrier upon written request or agreement of the employee (total amount may not exceed net preinjury wages).

§408.003(b) requires the carrier to pay the employer those benefits to which the employee was entitled but which the employer paid. It also provides that amounts which could not be reimbursed under §408.003(b) are reimbursable out of IIBs under §408.127. However, to be eligible for reimbursement, the employer has to meet two conditions.

First, to be eligible for any reimbursement under T.L.C. §408.003, the employer must have timely reported the injury to the insurance carrier. Second, the employer must notify the commission and carrier of the initiation and amount of payments made. Thus, unless these two conditions are met, the employer is not entitled to reimbursement.

Assuming these two conditions are met and the claim is compensable, the employer is entitled to reimbursement.

Additional reimbursement from IIBs is provided to ensure that an employer’s initiation of benefits does not result in the employee receiving more than what the employee is entitled to in income benefits.

In the immediate case, the employer is making supplemental payments. These are not the type of payments which the statute anticipated being reimbursed. Since supplemental payments are voluntarily paid by the employer after the carrier has accepted the claim reimbursement under §408.003(b), and thus §408.127, does not apply.

04/13/00

00-05

SIBS

Rule 130.106(a) states that an injured employee who is not entitled to SIBs for a period of 4 consecutive quarters permanently loses entitlement to such benefits. If a insurance carrier disputes entitlement to 4 consecutive quarters of SIBs, when do these denials become final under rule 130.106?

20000425

The disputes do not become final until they are finally adjudicated before the Commission and/or the Courts. The insurance carrier will need to continue to review entitlement for subsequent quarters as long as the injured employee files for SIBs. In this specific fact situation, the injured employee must initiate the dispute resolution process for filing for a BRC pursuant to rules 130.108 and 141.1.

04/17/00

00-06

MEDICAL RECORDS

Who is responsible for sending medical records to the RME doctor? Many insurance carriers are advising injured employees that they are responsible for obtaining and providing the records for an RME.

20000418

The insurance carrier should not be requiring the injured employee to obtain records for an RME. Since the request for the examination is made by the insurance carrier, the insurance carrier should notify the treating doctor to share the medical records with the insurance carrier's RME doctor as defined in rule 133.2.20000419

07

CONFIDENTIAL CLAIM INFORMATION

The agency is starting to receive e-mails from insurance carriers and injured employees containing claim specific information and questions regarding such. The party is able to satisfy all the requirements to receive and/or discuss confidential claim data (name, social security number, date of injury, employer, etc.)

May agency staff respond via e-mail when the response requires providing confidential information, or should the response be provided via telephone calls or hard copy/paper?

20000425

TWCC does not have the capability to securely respond to emails requesting confidential claim file information. Confidential claim file information should only be released by hard copy/paper or phone call once the appropriate verification has been made.

05/01/00

00-08

TWCC-34

When a Dispute Resolution Officer receives a TWCC34 and a designated doctor is assigned to resolve MMI/IR, do we ask the designated doctor to address disability if the RME doctor releases claimant to return to work?

20000509

It would not be inappropriate to contact the designated doctor regarding disability in this situation.

05/01/00

00-09

BRC/MMI/IR/DD

If a BRC is set on release to return to work and MMI/IR, and at the BRC does the carrier request that the Designated Doctor also address disability? If so, do we contact the Designated Doctor already set or do we assign a different designated doctor?

20000509

If the designated doctor has not performed the exam, it would be appropriate to request the designated doctor to address disability also. In most cases the resolution of MMI/IR would also resolve the disability issue. If the insurance carrier continues to dispute disability after the designated doctor has performed his evaluation, the BRO may request a clarification from the designated doctor regarding disability

05/01/00

00-10

TIBS/DD/TWCC-34

When a claimant no-shows for Designated Doctor appointment, can the carrier stop TIBS if the designated doctor was set on the TWCC-34?

20000509

Rule 126.6(h) allows for suspension of TIBs if the injured employee fails to attend an RME or designated doctor examination, without good cause. However, such suspension is only permitted as outlined in 126.6(h).

05/01/00

00-11

DD

A field office OAO selected a designated doctor (DD) and made an appointment. Claimant missed the appointment because the notice went to the wrong address. Since this DD travels into the area only once a month and it would take several weeks to get another appointment, would it be appropriate to use a different DD?

20000509

Generally, no. Selection of a different doctor reduces the impartiality of the selection process.

In this specific fact situation the injured employee’s failure to attend was because of an incorrect address. Selection of a different designated doctor would be appropriate in this case as the designated doctor would be unavailable.

05/23/00

00-12

SIBS

If a insurance carrier paid a quarter of SIBS based on a CCH D&O, and the Appeals Panel reversed the HO's decision, is the insurance carrier supposed to recoup the over-payment from future SIBS rather than the SIF?

20000606

Rule 116.11(b), effective March 13, 2000, says that an insurance carrier should not seek SIF reimbursement for benefits recoverable or convertible from other income benefits. Insurance carriers seeking to recoup such overpayments (particularly those that don’t involve recouping from IIBs) need to attempt to seek the express agreement of the injured employee. If such agreement is not reached, the insurance carrier may request a BRC. If a injured employee is no longer eligible for SIBs, insurance carriers should seek reimbursement from the SIF.

05/23/00

00-12

SIBS

If a insurance carrier paid a quarter of SIBS based on a CCH D&O, and the Appeals Panel reversed the HO's decision, is the insurance carrier supposed to recoup the over-payment from future SIBS rather than the SIF?

20000606

Rule 116.11(b), effective March 13, 2000, says that an insurance carrier should not seek SIF reimbursement for benefits recoverable or convertible from other income benefits. Insurance carriers seeking to recoup such overpayments (particularly those that don’t involve recouping from IIBs) need to attempt to seek the express agreement of the injured employee. If such agreement is not reached, the insurance carrier may request a BRC. If a injured employee is no longer eligible for SIBs, insurance carriers should seek reimbursement from the SIF.

06/27/00

00-13

SECTION 408.147 / AP 962504

The insurance carrier disputes a quarter of supplemental income benefits by requesting a benefit review conference. The day before the BRC the insurance carrier informs the injured employee's attorney that it would accept liability for the quarter and the BRC was canceled. Is the insurance carrier liable to pay the injured employee's attorney's fees incurred as a result of the insurance carrier's dispute?

06/27/00

Yes. In accordance with Rule 130.108, the insurance carrier who unsuccessfully contests the Commission determination of entitlement to SIBs is liable for reasonable and necessary attorney's fees incurred by the injured employee as a result of an insurance carrier's dispute which are ordered by the Commission or the Court. The carrier withdrawal of its dispute the day prior to the BRC is tantamount to an unsuccessful contest. If the claimant incurred attorney fees prior to the carrier's withdrawal of the dispute, the carrier must comply with any order to pay those fees.

07/11/00

00-14

MEDICAL BILLING / PEER REVIEW / RULE 133.300

Does Rule 133.300(h) cover charges a doctor would bill a carrier for when they have performed a peer review for the doctor?

07/21/00

"No. Contract disputes between the carrier and the peer review doctor are outside the scope of the Texas Workers' Compensation Act and Rules.

06/23/00

00-15

REIMBURSEMENT

What protection is there for health care providers when they reimburse a private HMO and try to collect from a workers' compensation carrier?

Scenario:

Injured worker went to health care provider for services, and did not tell them it was a workers' comp injury. The health care provider bills the HMO, then bills the injured worker for the deductible and copay for services rendered in 1998. Now in June 2000, the injured worker notifies the health care provider that he had a workers comp injury in 1998 and that they should be billing the insurance company providing workers' comp coverage. The health care provider reimburses the HMO, then contacts the insurance company for payment on the 1998 bills. The insurance carrier states they will not pay them because it is past the time limit from the date of service that they have to submit a bill to them. Big Question: Is health care provider stuck with the bill?

08/15/00

The Act and Rules do not provide timelimits for carrier review of medical bills for services provided prior to 9/1/99. Therefore, the carrier was required to review the bills and take action in accordance with the Act, Rules and Commission Guidelines. In this case, the carrier issued a denial stating that the timelimit to review the bills had expired. This was an insufficient reason for a denial since, as noted, for dates of service prior to 9/1/99, there was no timelimit for submitting bills that would result in nonentitlement if exceeded.

07/14/00

00-16

DESIGNATED DOCTOR / RULE 130.6 / ADJUDICATED / MEDICAL FEE GUIDLEINES /

A designated doctor examined a claimant at the commission's request and billed the carrier in conformity with Rule 130.6.(r) for 2 body areas, the shoulder and the neck as indicated in the medical history. The carrier reduced the bill by $150.00 because the shoulder had been adjudicated not compensable. Is this appropriate? If yes, who is responsible for the bill?

08/15/00

Yes, the doctor is not entitled to reimbursement for body parts that were previously adjudicated prior to the exam.

If there had been no resolution to the extent of injury issues the carrier would be responsible for payment of the entire exam.

07/25/00

00-17

RME / FORMS / REFUSAL OF EXAM / RULE 126.6

Can an RME doctor require an injured employee to sign forms as a requisite to an RME? Does it make a difference if the form is not objectionable to the Commission? If the employee refuses to sign a form (assuming the form is not an improper release or other inappropriate form) and therefore the doctor refuses to examine the employee, is it a violation of the Commission rules by the employee.

08/15/00

Doctors expect patients to fill out forms both inside and outside the workers’ compensation system. Often the information is necessary for billing or safety reasons (such as letting the doctor know what medications the patient is on). In other cases the forms can help document the patient’s understanding of the purpose and scope of the examination. These are standard office procedures for health care providers. As such, the Commission expects injured employees fill out and sign routine forms as a part of submitting to the RME. An unwillingness to do so might be considered a refusal to submit to the examination. If such a refusal causes cancellation of the examination and it is found that the employee did not have good cause, then commits an administrative violation and may lose entitlement to temporary income benefits (TIBs).

However, at the same time, the Commission is aware of doctors attempting to require an employee to sign a form which would make the employee liable for the cost of treatment (without indicating that said liability would only occur if §413.042(a)(1) or (2) apply). In other cases, the Commission has found doctors whose forms would allow for the release of medical information to a party other than the employee’s insurance carrier. Forms that attempt to create a waiver of the employee’s rights are inappropriate and the employee is not expected to sign them. If an employee’s refusal to sign an inappropriate form results in cancellation of the examination, the employee does not commit an administrative violation and does not lose entitlement to TIBs.

07/25/00

00-18

MEDICAL FEE GUIDELINE / CPT CODE / REIMBURSEMENT / MEDICAL REVIEW / DEFINITION / EACH /

What is the definition of the word "each" (as used in the CPT Code Descriptor 97110). Please define as the Commission (as a whole) would use the word.

A Findings and Decision was issued by a Medical DRO in the field against a Healthcare Provider that billed this code for only 3-minutes of work. The HCP billed the carrier for the full $35.00. The MDRO did not allow reimbursement because the CPT Code Descriptor says that reimbursement will be at $35.00 for each 15-minutes.

The Healthcare Provider had billed this code for only 3-minutes of work. The HCP billed the carrier for the full $35.00. Reimbursement was not allowed because the CPT Code Descriptor says that reimbursement will be at $35.00 for each 15-minutes.

08/15/00

The Medical Fee Guideline (MFG) Medicine section briefly discusses allowances for reimbursement of additional time spent in a timed physical medicine procedure . There are no guidelines to determine a prorated reimbursement if all of "each 15 minutes" is not used.

The Anesthesia Ground Rule section I.B.2. explains that time units shall be calculated in fifteen minute intervals, or portion thereof, with each interval equal to one time unit. This implies that an 18 minute procedure would count for 2 units of reimbursement. Since this interpretation is an acceptable standard of measurement for reimbursement of a medical service, then it is considered an acceptable standard to determine medical benefits.

08/14/00

00-19

RELEASE / CLAIM FILE / CONFIDENTIAL INFORMATION / ATTORNEY /

If an attorney has not yet filed a letter of representation with the commission and calls for the TWCC number for the claim, can we release the information if the attorney is able to satisfy all the requirements to receive and/or discuss confidential claim data (i.e., name, social security number, date of injury, employer, etc.)

08/17/00

Yes, as long as the attorney can satisfy at least three of the required pieces of information to document a claim, the fourth or missing information may be released.

If additional information is requested or copies of the record are needed the attorney would be required to furnish his letter of representation.

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