Greetings, earlier this week we did a live CEU for a client (boy is it good to get out and see everyone again), and I thought it would be a good refresher to cover how to handle Hospital bills listed on a PFB.
One of the problems we often face is the hospital bill may be attached but not actual records. The adjuster may not have a clue as to why the claimant went to the hospital or what they were treated for at the visit. And the clock is running, we have 30 days to provide a response to the PFB to avoid owing the claimant’s attorney fees.
I have heard some adjusters want to deny a hospital visit if the claimant has an authorized treating doctor. Sometimes that is the right decision, if the claimant is clearly taking advantage, etc…However, “emergency” treatment arguably doesn’t require pre-authorization by the Employer/Carrier under 440.13(3), if the need for care arose from the accident. And if you call any orthopedic or walk-in clinic, the recording says if this is an emergency, go to the hospital. If the claimant tells the Judge they were in extreme pain, and they called their authorized doctor, and then went to the hospital, we may very well get stuck with the bill if the JCC accepts that testimony. This is definitely a case-by-case, so discuss with your defense attorney.
So, how do you handle an unknown bill for an unknown treatment? The problem is the traditional answer could expose you to fees: the E/C will request the bill on proper form and at fee schedule and pay IF causally related to the accident. Unfortunately, if we don’t make that decision within 30 days of the PFB date, we are going to owe fees if after getting the records you decide to pay it. IF related is not providing the benefit, it’s a big fat maybe. Per a recent JCC, “the Employer/Carrier placed a contingency on their responsibility for the medical bills and therefore, did not accept or deny responsibility within 30 days.”
The better answer that will protect you from paying for unrelated treatment and avoiding fees is:
The E/C will request the bill on proper form and at fee schedule and pay for any treatment for the _(insert your compensability body parts).
That way if the claimant went to the ER for a heart attack, you are not on the hook, but you also avoid attorney fees.
After responding to the PFB within 30 days, the claimant can not claim fees even if the bill is not paid within the 30 days. Per the Sansone case “when it comes to medical benefits, a claimant’s successful prosecution ends when the carrier or employer accepts responsibility, regardless of when the carrier or employer actually pays the medical providers.”
However, that doesn’t mean you can do nothing. We need to request the bill on proper form and at fee schedule and follow up till we get it and pay. There is case law that would support fees being owed if no efforts are made after the PFB response. Document, document, document your efforts to get the bill and get it paid!
Morgan Indek | Managing Partner