Make Sure Disputed Bills are Authorized when Asserting AHCA Defense

Tuesday, September 11, 2012 | 0

I’ve written before about the employer/carrier's (E/C) jurisdictional defense to a claim for unpaid bills from authorized providers. The claimant has no standing to sue for payment of the bills and the judge has no jurisdiction to order the payment of the bills.

Only the Agency for Health Care Administration (AHCA) has jurisdiction to settle such disputes. In fact, Sections 440.13(11)(c) and 440.13(3)(g) state that the claimant does not have responsibility for such bills. In the past, I’ve written the following on the matter:

“Section 440.13(11)(c) dictates that the Agency for Health Care Administration (“AHCA”) has “exclusive jurisdiction” to decide any matters regarding provider reimbursement. As long as the carrier authorizes care with the doctor, the dispute about the doctor’s bills is outside the jurisdiction of the Judges of Compensation Claims.”

However, it is important that when the E/C asserts this defense, it is “buying” the bills and the treatment connected with said bills.

In Bergstein v. Palm Beach County School Board, the claimant appealed the trial court’s decision to deny his claim for unpaid medical bills. The 1st District Court of Appeals reaffirmed its prior rulings in Orange County v. Willis and Cook v. Palm Beach County School Bd., but this time, the court emphasized the consequence for the E/C for asserting this defense.

The 1st DCA found that the E/C made a “binding legal concession” per s. 440.32(3). This section gives the judge powers to impose sanctions against any attorney that signs a pleading and violates said pleading or signs the pleading in bad faith. Serious stuff.

Furthermore, the E/C waives any defense of medical necessity of the treatment provided in the bills. This way the claimant is completely “insulated” from any responsibility of having to pay said bills.

In presenting this defense, the E/C represents to the judge that bills are from authorized providers for compensable conditions. This means there is no denying of this treatment later on based on medical necessity. The E/C is essentially “buying” this treatment, much like the three-day rule under S. 440.13(3)(d).

It looks to me that the court is holding E/C’s to this defense and setting up possible sanctions should an E/C assert the defense and then deny the same treatment they say was authorized. For adjusters, it is very important to research and confirm that such medical treatment was in fact authorized before asserting the jurisdictional defense. Simply throwing the defense out there to keep claimant’s case out of the judge’s hand is not a smart move.

Now, this case is not specific enough as to when the defense is asserted, does it become binding?  For example, if the adjuster asserts the defense in a response to a petition for benefits, does that make the acceptance of the bills as binding? By using the language of S. 440.32(3), I believe the court is referring to when the E/C’s attorney asserts the defense in a pleading, like the pretrial stipulations.

However, adjusters should still be vigilant and positive that the bills are for authorized and compensable care before utilizing the jurisdictional defense in their responses or Notice of Denial.

Michael Rabinowitz is a shareholder at Banker Lopez Gassler, a workers' compensation defense firm in Tampa, Fla. This column was reprinted with his permission from his Workers' Comp Corner blog.