When Health Care Providers May File As Subclaimants

Saturday, August 12, 2006 | 0

The Division of Workers' Compensation (DWC) has provided clarification regarding health care providers filing as subclaimants to compensability and extent of injury disputes. The clarification was provided in the April/May 2006 edition of the DWC's Health Care Technical Update.

The DWC said Section 413.042 of the Texas Labor Code prohibits the billing of injured employees and their private health care insurance by health care providers for medical services related to an on-the-job injury or illness unless the DWC or a court has determined that the injury or illness is not compensable.

The Health Care Technical Update noted that an insurer may dispute that the injured employee sustained a compensable injury or dispute an injury or medical condition that is being treated as part of the compensable injury. The DWC said health care providers may not be able to collect payment for medical services rendered in cases where the injured employee does not pursue a final resolution of such a dispute through the DWC's dispute resolution process. In such an event, the health care provider may file for subclaimant status in order to pursue a final resolution of the dispute through the DWC as a subclaimant.

The DWC noted that Section 409.009 of the Texas Labor Codes provides that to qualify for subclaimant status, the health care provider must have provided health care to the injured employee and been refused payment for the health care by the insurer.

To file as a subclaimant, a health care provider must submit a letter on business letterhead to the local DWC field office manager stating that they have provided health care to an injured employee, billed the insurer, been denied payment by the insurer, and are requesting subclaimant status.

The DWC said that once a health care provider has been granted subclaimant status, the health care provider may be provided with information concerning the claim-related disputes where the health care provider has provided medical treatment or services to the injured employee, sought payment, and been denied reimbursement.

Did You Know?

An insurer may not withdraw a preauthorization or concurrent review approval. See DWC Rule 134.600(l).

An insurer must provide the party requesting preauthorization or concurrent review with an opportunity to discuss the clinical basis for a denial with the appropriate doctor or health care provider performing the review prior to the issuance of a preauthorization or concurrent review denial. See DWC Rule 134.600(m).

An employer may pay a workers' compensation medical bill. The health care provider must submit a copy of a medical bill paid by the employer to the insurer. The bill must include the following statement in bold type - THIS IS AN INFORMATION COPY, IT IS NOT A REQUEST FOR PAYMENT. See DWC Rule 134.801.

Communication between an insurer and health care provider related to the processing of a medical bill must be made by telephone or electronic transmission unless the information cannot be sent by those medias, in which case the sender must send the information by mail or personal delivery. See DWC Rule 133.3(b).

188 injured employees requested judicial review in 2004. Texas Workers' Compensation System Data Report, June 2005.

Insurers made 294 requests for judicial review in 2004. Texas Workers' Compensation System Data Report, June 2005.

In Texas, premiums average about $3 per $100 of payroll, the basis for premium calculations, compared with an average of $2.20 nationally. Insurance Information Institute Workers' Compensation Issues Update.

Carpal tunnel syndrome (CTS) injuries are ranked second behind back injuries as the leading lost-time diagnosis. Recent analysis conducted by NCCI confirms that carpal tunnel syndrome (CTS) injuries continue to account for a relatively modest 2% of total lost time claims. National Council on Compensation Insurance, Inc. May 2005 Research Brief - "Carpal Tunnel Claims Rank Second Among Major Lost Time Diagnoses".

A study of damage from a range of terrorism acts in four U.S. cities (New York, Des Moines, Washington D.C., and San Francisco) puts insured losses in the hundreds of billions for incidents involving nuclear, biological, chemical, and/or radiation bombs or agents (NBCR). In New York, where losses would be the highest of the four cities, a large NBCR event could cost as much as $778.1 billion with insured losses for commercial property at $158.3 billion and for workers' compensation at $483.7 billion. American Academy of Actuaries.

Republished with permission from the Insurance Council of Texas.

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