Greetings, I had a lot of feedback to last week’s Tip (below) regarding handling the 120, thought I would share some questions:
- If a condition is listed as a diagnosis by the treater, like Diabetes or HTN, but not treated, do we need to issue a denial? I would say no, what starts the 14 or the 120-day clocks is the provision of a benefit. And if no treatment was rendered, then no benefit was provided for those conditions.
- Do we need to issue a denial if there is a referral for an MRI/testing of a non-injured body part to “rule in or rule out” the cause of the symptoms? On this, it depends. If you are treating the neck and the doctor asks for an EMG which shows Carpal Tunnel, I think you should, to be safe, issue a denial at that point after the study. Arguably it wasn’t treated so you may be fine, but in an abundance of caution a denial is clearer. If you are treating the neck and the doctor asks for an MRI of the shoulder for rule in/rule out, I think in your authorization you should say something like, the shoulder condition is denied, authorized testing for rule in/rule out purposes only of the compensable neck injury.
- Are there ways to deny after 120 days if the claimant misses appointments, is uncooperative or lies? There is an escape hatch on the 120-day rule in the statute. Under 440.20(4), the carrier waives the right to deny compensability after 120 days”….unless the carrier can establish material facts relevant to the issue of compensability that it could not have discovered through reasonable investigation within the 120-day period.” Also, if the claimant’s actions rise to misrepresentation, the caselaw says you will be stuck with compensability.
As always, please feel to reach out with any questions!
Our events page on our website has flyers with links to all of our currently scheduled FL, GA and TN CEU webinars: https://eraclides.com/events/
In Orlando? Join us for Pilates and/or Pints on 10/1, Rsvp to eg@eraclides.com.
Join our GA CEU on Thursday, Email eg@eraclides.com for the registration link.
Sincerely,
Morgan Indek | Managing Partner