Atlanta Workers Compensation Law : Atlanta Workers' Compensation Lawyer & Attorney : Seth Bader Law Firm : Construction Accidents, Repetitive Motion Injuries, Disability : Atlanta, Marietta, Roswell, Georgia

(a)

(1)  The employer/insurer have a duty to provide all reasonable and necessary medical treatment in a timely manner and to give appropriate assistance in contacting medical providers when necessary.  The employee has a continuing obligation to cooperate with medical providers in the course of their treatment for work related injuries.

(2)  Payment of compensation for costs by the employer or its insurer directly to the providers of medical, surgical and hospital care and other treatment, items, or services on behalf of the employee or directly to the employee shall satisfy employer's obligation to furnish the employee compensation for costs of such medical, surgical, hospital care and other treatment, items and services provided for by O.C.G.A. § 34-9-200(a).

(b)

(1)  Changes in treatment.  Except as provided in subsection (b) of O.C.G.A. § 34-9-201, changes of physician or treatment are made only by agreement of the parties or by order of the Board.  If there has been no hearing requested, a party requesting a change shall make a good faith effort to reach agreement on the change before requesting an order from the Board.

If an agreement cannot be reached, the party requesting the change shall make the request on a Form WC-200b.  When filing the WC-200b, the moving party shall sign the Form WC-200b, attach supporting documentation including a separate certificate of service identifying the names and addresses serviced attached to the end of the request, and serve a copy on all counsel and unrepresented parties.  In cases that have been designated as "Medical Only", the requesting party shall file a Form WC-14 Notice of Claim or a Form WC-1 along with the Form WC-200b in order for the Board to process the request.  The party making the request must specify the reason for the requested change, as well as the date that the change shall be effective.  If the argument in support of the request is based on testimony, then an affidavit must be attached to the form, and if the argument refers to documents, then a copy of the documents must be attached.  Do not use tabs to separate documents used as evidence.  If the Board grants a change, the effective date will be the date that the Form WC-200b was filed, unless otherwise specified.

Any party who objects to the request for a change of physician or treatment shall also file their objection on a Form WC-200b with the Board within 15 days of the date of the certificate of service on the request, including a separate certificate of service identifying the names and addresses served attached to the end of the objection, and serving a copy on all unrepresented parties and counsel.  Affidavits and documents must be attached as specified above.

All requests and objections to change of physicians shall be filed on a Form WC-200b and shall be limited to 50 pages, including briefs and exhibits, unless otherwise permitted by an Administrative Law Judge or the Board.

Whenever the pending issues in a request resolve, in part or in whole, the parties or attorneys shall immediately notify the assigned Administrative Law Judge:

(1)  first, by telephone call; and

(2)  if so instructed, by subsequent written or electronic confirmation.

Any party or attorney who fails to follow this procedure, and who is unable to show good cause for such failure, may be subject to civil penalties and/or assessed attorney's fees.

If a hearing has been requested, the party requesting a change of physician or treatment may include the request in the original request for hearing, or amend the hearing request within 15 days prior to the date of the hearing to include the issue of change of physician or treatment.  Upon consideration of the evidence, the Administrative Law Judge will render a decision on all the issues presented.

If the parties agree on a change of physician or treatment, a properly executed Form WC-200a may be filed with the Board, with copies provided to the named medical provider(s) and parties to the claim, which form shall be deemed approved and made the order of the Board pursuant to O.C.G.A. § 34-9-200(b), unless otherwise ordered by the Board.

(2)  The party requesting/objecting to a change in physician shall set forth reasons why the change will/will not benefit the employee, or provide the employee with medical care reasonably required to effect a cure, give relief, or restore the employee to suitable employment.  Factors which may be considered in support of the request/objection may include, but are not limited to, the following:

(i)  Proximity of physician's office to employee's residence;

(ii)  Accessibility of physician to employee;

(iii)  Excessive/redundant performance of medical procedures;

(iv)  Necessity for specialized medical care;

(v)  Language barrier;

(vi)  Referral by authorized physician;

(vii)  Noncompliance of physician with Board Rules and procedures;

(viii)  Panel of physicians;

(ix)  Duration of treatment without appreciable improvement;

(x)  Number of prior treating physicians;

(xi)  Prior requests for change of physician/treatment;

(xii)  Employee released to normal duty work by current authorized trea ting physician;

(xiii)  Current physician indicates nothing more to offer.

(3)  When filing a motion for reconsideration, the parties or attorneys shall:

(1)  immediately notify the Board or assigned Administrative Law Judge by telephone call;

(2)  use the ICMS doc-type labeled motion for reconsideration;

(3)  limit their motion to 20 pages, including briefs and exhibits, unless otherwise permitted by the Board or an Administrative Law Judge; and

(4)  serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.

(c)

(1)  As long as an employee is receiving compensation, he or she shall submit himself or herself to examination by the authorized treating physician scheduled by the employer/insurer at reasonable times and with reasonable notice.  If the employee refuses to submit himself or herself to or in any way obstructs such an examination requested by and provided for by the employer, upon order of the board his or her right to compensation shall be suspended until such refusal or objection ceases and no compensation shall at any time be payable for the period of suspension unless in the opinion of the board the circumstances justify the refusal or obstruction.

(2)  Nothing contained herein shall be construed to abridge the employee's continued right to schedule his/her appointments for authorized medical treatment.

(d) The employer/insurer may suspend weekly benefits for refusal of the employee to submit to treatment only by order of the Board.

(e)  Medical Reports

The employer/insurer shall not file with the Board a medical report for any injury which occurred after January 1, 1989, except as follows:

(1)  The report or its attachments contains a permanent partial disability rating (file within 10 days of employer/insurer's receipt);

(2)  A rehabilitation plan is filed with the Board. In such instance the medical reports shall be filed with the rehabilitation plan;

(3)  Medical reports are requested by the Board (file within 10 days of request.)  Any additional medical reports required shall be filed within 10 days of the employer/insurer's receipt of same.  The employer/insurer shall maintain copies of all medical reports in their files and shall not file medical reports except in compliance with this Rule.

(f)

(1)  Requests for Medical Information.  The employee shall, upon the request of the employer/insurer, furnish copies of all medical records and reports which are in his/her possession concerning the treatment for the accident which is the subject of the claim.  The employee shall furnish the copies within 30 days of the date of the request.  The employer/insurer shall pay the reasonable cost of the copies as provided by the Board-approved fee schedule.

(2) The employer/insurer shall, upon the request of the employee, furnish a copy of the posted panel of physicians, and copies of all medical records and reports in their possession concerning the treatment for the accident which is the subject of the claim, and shall, upon request of the employee, furnish copies of all medical records and reports which were obtained with a release of the employee provided pursuant to O.C.G.A. § 34-9-207(b), within 30 days of the date of the request at no expense to the employee.

(3)  Upon failure of either party to furnish information as provided above, the physician or other medical providers shall, upon request, furnish copies of all medical reports and bills in their possession concerning the treatment for the accident which is the subject of the claim, at no expense to the employee or his/her attorney.  A reasonable cost for copies pursuant to the fee schedule may be charged against the party determined to be responsible for payment of medical expenses.  Nothing in this Rule shall limit an employee's right to obtain a complete copy of his/her medical records from any health care provider.

(g)  Physicians as defined in O.C.G.A. § 34-9-201(a) may be called upon and may be issued a subpoena requiring their testimony as expert witnesses based upon their examinations and treatment of employees alleging work-related injuries.  In lieu of live testimony at hearings in cases pending before the State Board of Workers' Compensation regarding matters subject to the Act, as permitted under O.C.G.A. § 24-10-24, depositions may be taken pursuant to O.C.G.A. § 24-9-26 et seq and O.C.G.A. § 34-9-102(d)(3), and said physicians shall be compensated for their preparation time and actual time pursuant to the provisions of the Board approved Fee Schedule or by a fee agreement agreed to by the parties and the physician.

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(a) Medical expenses shall be limited to the usual, customary and reasonable charges as found by the Board pursuant to O.C.G.A. § 34-9-205.  Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges.  Employer/insurers shall not unilaterally change any CPT-4 code of the provider.  All automatically conformed charges according to the fee schedule adopted by the Board shall be for the CPT-4 code listed by the provider.  In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third party administrator shall provide an Explanation of Benefits with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each Explanation of Benefits code used.  In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or employer/insurers who dispute the CPT-4 code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference or an evidentiary hearing by filing Form WC-14 with the Board.  For charges not contained in the fee schedule and which are disputed within 30 days as not being reasonable, usual and customary, the aggrieved party shall follow the procedures provided in subsection (b).

(b)

(1)  A medical provider or an employee who has incurred expenses for healthcare goods and services or other medical expenses shall submit the charges to the employer or its workers' compensation carrier for payment within one year of the date of service.  In the event that the claim or the expense is controverted, the medical expenses or request for reimbursement must be submitted for payment within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later.  Failure by the medical provider to submit expenses within the time prescribed shall result in waiver of such expenses.

(2)  Any challenge by a medical provider to the amount of payment for goods, services, or expenses shall be submitted to the payor within 120 days of payment.  Failure by a medical provider to challenge the amount of payment of such goods, services, or expenses within 120 days shall result in the waiver of additional payment.

(c) Disputes

(1)  An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges which are disputed.

(2)  For charges not contained in the fee schedule and which are disputed as not being the usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 30 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel.  A request for peer review of chiropractic charges or treatment shall attach to the application 10 copies of the charges and all of the reports dealing with the treatment of the injured employee.  A request for peer review of any other treatment or charges shall attach to the application two copies of the charges and all of the reports dealing with the treatment of the injured employee.

The peer review committees approved by the Board are as follows: Medical Directors Solutions, LLC; Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; and such other committees as the Board has posted as so designated at its Atlanta office.

(3)  Unless peer review is requested as set forth in Rule 203(c)(2), all reasonable charges for medical, surgical, hospital and pharmacy goods and services shall be payable by the employer or its worker's compensation insurer within 30 days from the date that the employer or the insurer receives the charges and the medical reports required by the Board. Failure of the health care provider to include with its submission of charges the reports or other documents required by the Board, constitutes a defense for the employer or insurer's failure to pay the submitted charges within 30 days of receipt; however, the employer or insurer must submit to the health care provider written notice indicating the need for further documentation within 30 days of receipt of the charges and failure to do so will be deemed a waiver of the right to defend a claim for failure to pay such charges in a timely fashion on the ground that the charges were not properly accompanied by required documentation.  Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment.

If any charges for health care goods or services are not paid when due, penalties shall be added to such charges and paid at the same time as, and in addition to, the charges claimed for the health care goods and services. For any payment of charges made more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10% of the amount due. For any payment of charges made more than 60 days after the due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20% of the amount due.  For any charges not paid within 90 days of the due date, in addition to the 20% add-on penalty, the employer or insurer shall pay interest on the combined total in an amount equal to 12% per annum from the 91st day after the date the charges were due until full payment is made. All such penalties and interest shall be paid to the provider of the health care goods or services.

(4)  The employer, insurer, or physician requesting review must comply with the requirements of the statute, Board Rules, and rules of the appropriate peer review committee before the Board will rule on any disputed charges.

(5)  If there is no appropriate peer review committee, the party requesting review may request a mediation conference by filing Form WC-14 with the Board.  The charges submitted which conform to the list as published by the Board shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided.

(6)  The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference or an evidentiary hearing. The peer review committee shall serve a copy of its decision upon the employee if unrepresented, or the employee's attorney.  A physician whose fee has been reduced by the peer review committee shall have 30 days from the date that the recommendation is mailed to request a mediation or hearing.  In the event of a hearing or mediation conference, the recommendations of the peer review committee shall be evidence of the usual, customary, and reasonable charges.

(7)  In cases where the peer review committee recommends that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review committee less the filing costs initially paid by the employer/insurer.  In the event the peer review committee recommends the entire fee be disallowed, the employer/insurer may automatically deduct the filing costs for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury.

(d)  Medical expenses shall include the reasonable cost of attendant care that is directed by the treating physician, during travel or convalescence.

(e)  Medical expenses shall include but are not limited to the reasonable cost of travel between the employee's home and the place of examination or treatment or physical therapy, or the pharmacy. When travel is by private vehicle the rate of mileage shall be 40 cents per mile.  This rate is subject to change based upon changes in fuel costs.  Travel expenses beyond the employee's home city shall include the actual cost of meals and lodging.  Travel expenses shall further include the actual cost of meals when total elapsed time of the trip to obtain outpatient treatment exceeds four hours. Cost of meals shall not exceed $30 per day.

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(a)  Reports required by the Board include State Board of Workers' Compensation Form WC-20(a), or HCFA 1500, HCFC 1450, UB-04 or UB92 and supporting narrative, if any, properly filled out and with supporting itemized hospital charges, discharge summary, and billings from other authorized providers of service and shall be furnished at no charge to the party responsible for payment.  Medical services provided pursuant to the Workers' Compensation Act are not confidential to the employer/insurer who by law are responsible for the payment of services.  Hospitals and other medical providers who by their own rules require medical releases shall be responsible for obtaining same at the time of treatment.

(b)

(1)  Medical treatment/tests prescribed by an authorized treating physician shall be paid, in accordance with the Act, where the treatment/tests are:

(a)  Related to the on the job injury;

(b)  Reasonably required and appear likely to accomplish any of the following:

(1)  Effect a cure;

(2)  Give relief;

(3)  Restore the employee to suitable employment;

(4)  Establish whether or not the medical condition of the employee is causally related to the compensable accident.

(2)  Advance authorization for the medical treatment or testing of an injured employee is not required by this Chapter as a condition for payment of services rendered.  A Board certified WC/MCO may provide for pre-certification by contract with network providers pursuant to O.C.G.A. § 34-9-201(b)(3).

(3)

(a)  An authorized medical provider may request advance authorization for treatment or testing by completing Sections 1 and 2 of Board Form WC-205 and faxing or emailing same to the insurer/self-insurer. The insurer/self-insurer shall respond by completing Section 3 of the WC-205 within five (5) business days of receipt of this form.  The insurer/self-insurer's response shall be by facsimile transmission or email to the requesting authorized medical provider.  If the insurer/self-insurer fail to respond to the WC-205  request within the five business day period, the treatment or testing stands pre-approved.

(b)  In the event the insurer/self-insurer furnish an initial written refusal to authorize the requested treatment or testing within the five business day period, then within 21 days of the initial receipt of the WC-205, the insurer/self-insurer shall either:

(a) authorize the requested treatment or testing in writing; or

(b) file with the Board a Form WC-3 controverting the treatment or testing indicating the specific grounds for the controversion.

(c)

(1)  If medical treatment is controverted on the ground that the treatment is not reasonably necessary, the burden of proof shall be on the employer.  If the treatment is controverted on the grounds that the treatment is either not authorized or is unrelated to the compensable injury, the burden of proof shall be upon the employee.

(2)  In the event of a dispute as to the necessity and/or reasonableness of services already rendered, the procedure listed in Board Rule 203(c) shall be followed.

(d)  If an employer or insurer utilizes a Board certified WC/MCO pursuant to O.C.G.A. § 34-9-201(b)(3), and a dispute arises regarding the treatment/test prescribed by the authorized treating physician and the dispute is not resolved within 30 days as outlined in Rule 208(f), then the employer or insurer has 15 days from notification by the WC/MCO to authorize the treatment/test or controvert the treatment/test.  In no event will the employer or insurer utilizing a WC/MCO have more than 45 days from the receipt of the notice of a dispute as set forth in Rule 208(f) to comply with this provision.

(4)  Where the employer fails to comply with Rule 205(b)(3), the employer shall pay, in accordance with the Chapter, for the treatment/test requested.

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(a)  Form WC-206, including supporting documentation, shall be submitted to the Board by the party seeking reimbursement during the pendency of the claim.  Copies shall also be sent by the party requesting reimbursement to all counsel and unrepresented parties at interest.

(b)  If a hearing request is pending when the Board receives a request for reimbursement and designation as a party at interest, the Board will provide the requesting party with notice of the hearing.

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This report and/or the HCFA 1500, HCFA 1450, and/or UB92 shall be completed and filed as follows:

(A)  The attending physician or other practitioner makes the report and forwards it along with office notes and other narratives to the employer/insurer as follows:

(i)  Within seven days of initial treatment;

(ii)  Upon the employee's discharge by the attending physician;

(iii)  At least every three months until the employee is discharged;

(iv)  Upon the employee's release to return to work;

(v)  When a permanent partial disability rating is determined.

(vi)  Pursuant to Rule 203(b).

(B)  The employer/insurer shall file the report including office notes and narratives with the Board within 10 days after receipt as follows:

(i)  When the report contains a permanent partial disability rating;

(ii)  Upon request of the Board; and,

(iii)  To comply with other rules and regulations of the Board.

(C)  The employer/insurer shall maintain copies of all medical reports and attachments in their files and shall not file medical reports except in compliance with this rule and Rule 200(c).

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(a)  The pecuniary liability of the employer for medical, surgical, hospital service, or other treatment required, when ordered by the board, shall be limited to such charges as prevail in the State of Georgia for similar treatment of injured persons of a like standard of living when such treatment is paid for by the injured persons.

(b)  The employer shall not be liable in damages for malpractice by a physician or surgeon furnished pursuant to this chapter, but the consequences of any malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.

(c)

(1)  All reasonable charges for medical, surgical, hospital, and pharmacy goods and services shall be payable by the employer or its workers' compensation insurer within 30 days from the date that the employer or the insurer receives the charges and reports required by the board.  The employer or insurer shall, within 30 days after receipt of charges for health care goods or services, mail to the provider of such health care goods or services payment of such charges or a letter or other written notice that states the reasons the employer or insurer has for not paying the claim, either in whole or in part, and which also gives the person so notified a written itemization of any documents or other information needed to process the claim or any portion thereof.

(2)  The failure by the employee or the health care goods or services provider to include with its submission of charges any reports or other documents required by the board shall constitute a defense for the employer's or insurer's failure to pay the submitted charges within 30 days of receipt of the charges.  However, if the employer or insurer fails to send the employee or the health care goods or services provider the requisite notice indicating a need for further documentation within 30 days of receipt of the charges, the employer and insurer will be deemed to have waived the right to defend a claim for failure to pay such charges in a timely fashion on the grounds that the charges were not appropriately accompanied by required reports.  Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment.

(3)  If any charges for health care goods or services are not paid when due, or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due, penalties shall be added to such charges and paid at the same time as and in addition to the charges claimed for the health care goods or services.  For any payment of charges paid more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10 percent of the charges. For any payment of charges paid more than 60 days after their due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20 percent of the charges.  For any charges not paid within 90 days of their due date, in addition to the 20 percent add-on penalty, the employer or insurer shall pay interest on that combined sum in an amount equal to 12 percent per annum from the ninety-first day after the date the charges were due until full payment is made.  All such penalties and interest shall be paid to the provider of the health care goods or services.

(4)  Notwithstanding any other provision of this subsection, if the employee or the provider of health care goods or services fails to submit its charges to the employer or its workers' compensation insurer within one year of the date of service or the issuance of such goods or services or, in the case of an employee, within one year of the date of incurring of mileage expenses, then the provider is deemed to have waived its right to collect such charges from the employer, its workers' compensation insurer, and the employee; and, in regard to mileage expenses, the employee is deemed to have waived his or her right to collect such charges from the employer or its workers' compensation insurer.

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(a)  Any party to a claim under this chapter, a group insurance company, or other health care provider who covers the costs of medical treatment for a person who subsequently files a claim under this chapter may give notice in writing to the board at any time during the pendency of the claim that such provider is or should be a party at interest as a result of payments made in the employee's behalf for medical treatment.

(b)  In cases where a group insurance company or other health care provider covers the costs of medical treatment for a person who subsequently files a claim and is entitled to benefits under this chapter, the board shall be authorized to order the employer or workers' compensation insurance carrier to repay the group insurance company or other health care provider the funds it has expended for the claimant's medical treatment, provided that such employer or its workers' compensation insurance carrier is liable under this chapter for such medical treatment and provided, further, that such other provider has become or should be a party at interest pursuant to the provisions of subsection (a) of this Code section.  The employer or its workers' compensation insurance carrier deemed liable for such medical treatment shall not be obligated to pay such sums directly to the employee unless, and only to the extent that, it is proven that the employee has paid for such medical treatment himself.

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