Greetings, hope everyone is doing well.

Litigation is slowly starting to increase back to pre-pandemic levels, and so is the flood of PFB’s.   Since April, the number of new litigated WC claims in Florida is down 13% compared to 2019.  However, since September its only down 7%, so the numbers are increasing.  Along with that comes the inevitable PFB tricks and questions.  Here are some of the questions and issues I have seen recently:

• Referral to a specialist from an authorized doctor-  In your PFB response, you don’t have to name the doctor  (unless you already know who it will be).   A simple “an orthopaedic doctor is authorized and the appointment information will follow” is acceptable.  However, due to the delays in getting appointments these days, do not sit on the referral.   Responding that it is authorized and then not making an effort to get it set up could be considered not authorizing it and expose us to a fee.  What is an unreasonable time?  Well it depends…3 weeks is reasonable, 3 months is not typically reasonable.  Document, document, document all of your efforts to get it set up.   Even if it takes a few weeks, as long as you can document consistent efforts we should be in the clear.

 

• One-time change request in a PFB- You still only have 5 calendar days to respond with the name of the doctor you are authorizing.   You don’t need to put your response in a PFB response, you can send a letter/fax/email to opposing counsel within 5 days, and the respond to the PFB within 14/30 days to avoid a fee. 

 

• Referral to a specific doctor or specialist- The E/C still retains the right to select the doctor for the referral, unless that specific doctor is “medically necessary”.  For example, if the referral from your authorized treater is to Dr. Morgan who is the only one in Central Florida who cures patients with  magic beans, then a referral Dr. Morgan for magic beans treatment might be “medically necessary”.   But if it’s a general referral for a pain management doctor, and not a unique Dr. Morgan magic beans treatment, then the E/C retains the right to select the doctor.  The treatment still must be AHCA approved and not experimental. 

 

• Watch for Statute of Limitations issues- If we are going to deny the claim for the SOL expiring, it must be in the first responsive pleading.   So if you are going to do a DWC-12 denial and a PFB response, make sure that both state the SOL has expired.  If you have questions about whether the SOL has expired, discuss with a defense attorney before responding.   There is caselaw on prescriptions possibly extending the SOL window (Ginsburg case).

Keep up the good fight.

Dr. Morgan