Greetings and Happy New Year,

I have been asked to do a refresher on responding to PFB’s.  (For those of you that want more details, we do offer a CEU that we can present on this topic).

Here are a few key things to remember:

1. When do you have to respond-  Well…the WC statute and most carriers stress 14 days after the date it is date stamped as received by DOAH.   BUT, no claimant attorney fees are due or owing until after 30 days.  Sometimes you do need those extra 16 days to get records, figure out what is going on and whether you do owe the benefits requested.

Of note, you can file an amended PFB response within 30 days and not owe fees if new information comes to light and it turns out you do owe something you denied in the initial response.   On a 1-time change you still must respond within 5 days, but you could do that outside of a PFB response.

2. Do not wait for appointment dates of doctor names (unless it’s a 1-time change)-  If the PFB requests an orthopaedic per the referral of the walk-in clinic, you do not need to wait and get an appt date or even the name of a doctor.   The benefit is providing authorization for an orthopaedic, so you can simply respond with something similar to “the E/C will authorize an orthopaedic per the referral from the walk-in, appointment information will be provided separately.”   Of course if you have the information put it in the response, but do not wait and potentially respond late.

The exception of course is if the request is for a 1-time change.  Even if it is on a PFB, you still only get 5 calendar days to respond with the name of the doctor you will be authorizing.

3. Not responding to a PFB is a denial of all benefits requested EXCEPT it is not a denial for SOL or 120-day-  If you do not respond, it is considered that you are denying every benefit listed on the PFB  (that is unless you provided it within 30 days).

However, if you are denying the benefits because the Statute of Limitations has expired you MUST respond to the PFB and state the SOL has expired or we waive that defense.   Also, not responding to the PFB does not serve as a denial for purposes of denying a claim under the 120 day rule.

4. Costs  Due to some unfortunate caselaw, if you provide any benefits listed on the PFB that you were not already providing, we owe costs.  This is true even if you respond to the PFB the same day.   So, you can state no attorney fees due or owing but the E/C agrees to pay taxable costs upon proof.

If you do not provide any benefits or if you already provided the benefits before the PFB was filed you do not owe costs.  Costs are only due if the claimant is the “prevailing party”, meaning they got something more by filing the PFB.

To read any of my prior Tips of the Week, they all live on our website under our Blog, here is the link:   https://eraclides.com/category/morgans-tips-of-the-week/

Also, check the Events page of our website for upcoming FL, GA and TN webinars.   Our first FL 4 hour law and ethics webinar will be January 25^th, check back soon for the flyer to register.  https://eraclides.com/events/ or you can register here:

Please register for 4 HR Law & Ethics  on Jan 25, 2024 10:00 AM EST at:

https://attendee.gotowebinar.com/register/7932609593797249627

After registering, you will receive a confirmation email containing information about joining the webinar.

Sincerely,

Morgan Indek | Managing Partner