New Mexico Court Orders Employers to Pay for Medical Marijuana

The New Mexico Court of Appeals ruled that an insurer must reimburse a workers' compensation claimant for the cost of medical marijuana to treat his low back pain, even though the substance is illegal under federal law.

The court said the employer did not cite any federal law that would be violated by such a requirement and noted that the U.S. Justice Department has announced "a somewhat deferential enforcement policy" toward state marijuana laws.

New Mexico Gov. Bill Richardson signed into law a bill legalizing marijuana for medical use in the state in April 2007. The "Lynn and Erin Compassionate Use Act" permits cannibas production facilities licensed by the state Department of Health for distribution of marijuana to patients suffering from specific disorders, including severe chronic pain.

To read the full decision click HERE
 

Change of Condition v. Fictional New Injury

When a doctor releases an injured worker to light-duty work, or work with restrictions (such as no lifting over 10 pounds, or limited standing) the worker’s employer may offer the worker a light-duty job to accommodate those restrictions.

Thus, a worker who previously operated a forklift or stood at an assembly line all day may find himself answering phones or filing papers instead. Sometimes, these new light-duty jobs can continue for months or even years.  

But what happens when an injured worker returns to a light-duty job, only to have his condition worsen later? The courts have found that when this happens the injured worker has suffered either a “change of condition,” or a “fictional new injury.”

If the worker has had a “change of condition,” his entitlement to additional income may be barred if too much time has passed since his original date of injury. However, if the injured worker has suffered a “fictional new injury,” he may file a new claim with a new date of injury and will be entitled to income benefits if a doctor takes him out of work.

In the recent case of Scott v. Shaw Industries, the Supreme Court ruled on just such a situation and offered some guidance on what circumstances distinguish a “change of condition” case from a “fictional new injury” case.

The Scott case involved a woman, Ms. Scott, who worked as a carpet inspector. This job required her to stand for most of her workday. However, in 1996 she suffered a serious injury and part of her foot was amputated as a result. She remained out of work for nearly a year while she recovered from the operation and received workers compensation income benefits during that time.

Eventually Ms. Scott was fitted with a prosthesis and her doctor stated that she was capable of returning to light-duty work.  Her employer then offered her a light-duty job where she could sit or stand as needed. Ms. Scott returned to this job, but her prosthesis caused her to walk with an altered gait. This in turn, caused her to develop bilateral knee problems. As a result, she underwent surgery on both knees in 1997.

Following knee surgery, Ms. Scott returned to work her light-duty job for 12 more years. During that time the condition of her legs continued to deteriorate until, in 2009, her doctor took her out of work completely. Ms. Scott then filed a new claim for workers compensation income benefits, arguing that she had suffered a “fictional new injury” in 2009 when her doctor took her out of work. The insurance company disagreed, arguing that her disability stemmed from her original injury in 1996 and that her condition had merely changed for the worse.

The Supreme Court agreed with the insurance company and held that Ms. Scott suffered a change in condition and not a fictional new injury. This meant that her disability was related to her original date of injury in 1996 and not the date her doctor took her out of work in 2009. As a result, the statute of limitations barred her from collecting income benefits.

The most important fact that the Supreme Court cited in classifying Ms. Scott’s case as a change of condition was that Ms. Scott was offered work within her doctor’s restrictions. Because Ms. Scott had never been asked to work or physically exert herself beyond the limitations that her doctors had imposed, it could be assumed that the deterioration of her condition was inevitable, and would have happened whether she had been at work, at home, or anywhere else. 

Thus, the facts in Scott were in contrast to the facts in R.R. Donnelly v. Ogletree, where an injured worker had returned to work, but had been made to do strenuous work that was beyond his doctor’s restrictions. In that case, the injured worker was found to have suffered a new accident.

Read the Supreme Court’s decision in Scott here:

Scott V Shaw 

Can I choose the doctor for my work-related injury?

It depends.  If your employer had a valid Panel of Physicians posted in a conspicuous location on the date you were injured, you likely will be required to choose a physician from the list of physicians on the panel.  If no panel was posted or if the panel was not valid, however, you may (and likely will) be free to select your doctor.

If you are not happy with your first doctor for any reason, you have the right to make one change to another doctor without permission from your employer or its insurance company.  Note, however, that If your employer had a valid Panel of Physicians posted on your accident date, you are limited to making this change to another doctor on the panel.  On the other hand, if your employer did not have a valid panel posted, you may (and again likely will) be able to make this change to any doctor you choose.

To view other Workers' Compensation Questions and Answers, click on the "Q & A" Button.

What is a CT Scan?

A CT scan —  known as CT or computerized tomography — is an X-ray technique that produces images of your body that visualize internal structures in cross section rather than the overlapping images typically produced by conventional X-ray exams.  A CT Scan is usually able to show more detailed pictures of organs, bones, and other tissues than a conventional X-ray.

To learn more about CT Scans, how they're performed, and how to prepare for one, we recommend reading "About CT Scans" from the Atlanta Medical Center and watching "Video: CT Scan" from the Mayo Clinic.

To view other Workers' Compensation Questions and Answers, click on the "Q & A" Button.

 

What is an MRI?

MRI, which stands for Magnetic Resonance Imaging, is a way to get pictures of various parts of your body without the use of x-rays.  An MRI scanner consists of a large and very strong magnet (usually donut-shaped) in which a patient lies.  A radio wave antenna is used to send signals to the body and then to receive signals back.  The returning signals are then convented into pictures by a computer, which is attached to the scanner.

MRIs are used for a variety of reasons, but they are particularly good for looking at the brain, spinal cord, nerves, muscles, ligaments, tendons, and other "soft tissue" throughout the body.

To learn more about MRIs, how they're performed, and how to prepare for one, we recommend reading "Magnetic Resonance Imaging" from the Atlanta Medical Center and watching "Video: MRI" from the Mayo Clinic.

To view other Workers' Compensation Questions and Answers, click on the "Q & A" Button.

Board Rule 200. Compensation for Medical Care; Changes in Treatment; Filing of Medical Reports; Requests for Medical Information

(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.

To return to the Workers' Compensation Rules Index, click on the "Rule" Button.

Board Rule 201. Panel of Physicians

(a)  The employer may satisfy the requirements for furnishing medical care under O.C.G.A. § 34-9-200 in one of the following manners:

(1)

(i)  The employer may maintain a traditional posted panel of physicians that shall consist of at least six non-associated physicians, but is not limited to a minimum of six.  However, the Board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians or groups of physicians are not reasonably accessible.  The physicians selected under this subsection from the panel may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require without prior authorization from the Board; provided, however, that any medical practitioner providing services as arranged by a primary authorized treating physician under O.C.G.A. § 34-9-201(b)(1) shall not be permitted to arrange for any additional referrals.  The physicians and groups listed on the panel shall be counted as a separate choice from the others listed only if they are not associated with the other physicians and groups listed on the panel.  The minimum panel shall include an orthopedic physician, and no more than two physicians shall be from industrial clinics.  Further, this panel shall include one minority physician.  The minority physician so selected must practice within the State of Georgia or be reasonably accessible to the employee's residence.  "Minority" shall be defined as a group which has been subjected to prejudice based on race, color, sex, handicap or national origin, including, but not limited to Black Americans, Hispanic Americans, Native Americans or Asian Americans.  Failure to include one minority physician on the panel does not necessarily render the panel invalid.  The Board reserves the right to allow exceptions when warranted.  The employee may make one change from one physician to another on the same panel without prior authorization of the Board.  The party which challenges the validity of a panel shall have the burden of proving that the panel violates the provisions of O.C.G.A. § 34-9-201 and Board Rule 201.

(ii)  In the event that the Board has granted any exceptions to the panel requirements, all exceptions must be posted at the same location as the panel.

(2)  Conformed Panel of Physicians.  The employer may maintain a list of physicians that shall be known as the "conformed panel of physicians," which shall include a minimum of ten physicians, or professional associations, reasonably accessible to employees and providing the same types of healthcare services specified in Board Rule 201(a)(1) and the following additional healthcare services: general surgeons and chiropractors.  The physicians and groups listed on the panel shall be counted as a separate choice from the others listed only if they are not associated with other physicians and groups listed on the panel.  Further, this panel shall include one minority physician as specified in Board Rule 201(a)(1).  An employee may obtain the services of any physician from the conformed panel and may thereafter also elect to change to another physician on the panel without prior authorization of the Board.  The physician so selected will then become the authorized treating physician in control of the employee's medical care and may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require without prior authorization of the Board; provided, however, that any of the physicians to whom the employee is referred by the primary authorized treating physician shall not be permitted to arrange for any additional referrals.  The party which challenges the validity of the conformed panel shall have the burden of proving that the panel violates the provisions herein.

(3)  An employer or the workers' compensation insurer of an employer may contract with a workers' compensation managed care organization certified pursuant to O.C.G.A. § 34-9-208 and Board Rule 208.  A "workers' compensation managed care organization" (hereinafter "WC/MCO") means a plan certified by the Board that provides for the delivery and management of treatment to injured employees under the Georgia Workers' Compensation Act.  The party which challenges the validity of the WC/MCO panel shall have the burden of proving that the panel violates the provisions herein.  An employer utilizing a WC/MCO may satisfy the notice requirements of O.C.G.A. § 34-9-201(c) by posting a notice in prominent places upon the business premises which includes the following information:

(A)  The employer has enrolled with the specified WC/MCO to provide all necessary medical treatment for workers' compensation injuries.  An employee with an injury prior to enrollment may continue to receive treatment from the non-participating authorized treating physician until the employee elects to utilize the WC/MCO;

(B)  The effective date of the WC/MCO;

(C)  The georgraphical service area (by counties);

(D)  The telephone number and address of the administrator for the employer and/or WC/MCO who can answer questions about the managed care plan;

(E)  How the employee can access care with the WC/MCO and the toll-free 24-hour telephone number of the managed care plan that informs employees of available services.

(b)  The employer/insurer cannot restrict treatment of the employee to the panel of physicians, conformed panel of physicians, or WC/MCO when the claim has been controverted.  However, if the controverted claim is subsequently found to be or is accepted as compensable, the employee is authorized to select one of the physicians who has provided treatment for the work-related injury prior to the finding or acceptance of compensability, and after notice has been given to the employer, that physician so selected becomes the authorized treating physician.  The employee may thereafter make one change from that physician to another physician without approval of the employer and without an order of the Board.  However, any further change of physician or treatment must be in accordance with O.C.G.A. § 34-9-200 and Board Rule 200.

(c)  When a case has not been controverted but the employer fails to provide any of the procedures for selection of physicians as set forth in O.C.G.A. § 34-9-201(c), the employee is authorized to select a physician who is not listed on the employer's posted panel of physicians, conformed panel of physicians or WC/MCO.  After notice has been given to the employer, that physician so selected becomes the authorized treating physician, and the employee may make one change from that physician to another physician without approval of the employer and without an order of the Board.  However, any further change of physician or treatment must be in accordance with O.C.G.A. § 34-9-200 and Board Rule 200.

(d)  A party requesting a change of physician must do so in the manner prescribed by Board Rule 200.

To return to the Workers' Compensation Rules Index, click on the "Rule" Button.

Board Rule 203. Payment of Medical Expenses; Procedure When Amount of Expenses are Disputed

(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.

To return to the Workers' Compensation Rules Index, click on the "Rule" Button.

Board Rule 205. Necessity of Treatment; Disputes Regarding Authorized Treatment

(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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Board Rule 208. Managed Care Organization Rules

(a) Application and certification.
(1) All provisions of this Rule constitute the minimum requirements necessary to obtain and maintain certification as a WC/MCO under the Georgia Workers' Compensation Act. To obtain certification of a plan, application shall be submitted on a Form WC-208a accompanied by a non-refundable fee of $1,000.00 and shall include the following information:
(A) An audited financial statement evidencing the ability of the Managed Care Organization to comply with any and all financial requirements to insure the delivery of services the Board may prescribe.

(B) Complete disclosure should be made of the following individuals (an individual may act in more than one capacity):
(1) The names, addresses and resume of all directors and officers of the WC/MCO;

(2) The title, name, address, telephone number and resume of the person to be the day-to-day administrator of the WC/MCO;

(3) The title, name, address, telephone number and resume of the person to be the administrator of the financial affairs of the WC/MCO;

(4) The name, address, medical specialty and resume of the medical director;

(5) The name, address and telephone number of the WC/MCO's communication liaison for the Board, the insurer, the employer, and the employee; and

(6) The name and address or any other information requested by the Board regarding any entity, other than individual health care providers, with whom the WC/MCO has a joint venture or other agreement to perform any of the functions of the managed care plan, and a description of the specific function to be performed by each entity.
(C) The WC/MCO must insure provisions of quality services that meet all uniform treatment standards required by Georgia law and provide appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service.

(D) The WC/MCO must provide a description of its proposed geographic service area by county and specify the times, places and manner of providing services, including a statement describing how the WC/MCO will insure that an adequate number of each category of health care provider is available to give employees convenient geographic accessibility to all categories of providers and adequate flexibility to choose health care providers from among those who provide services under the plan.

(E) The WC/MCO must include minority providers, and at a minimum, the following types of health care services and providers, unless the WC/MCO provides evidence that a particular service or type of provider is not available in the geographical service area:
(1) Medical doctors, including specialists in at least one of the following fields: family practice, internal medicine, occupational medicine, or emergency medicine;

(2) Orthopedic surgeons, including specialists in hand and upper extremity surgery;

(3) Neurologists and neurosurgeons;

(4) General surgeons;

(5) Chiropractors;
(6) Physical and occupational therapists;

(7) Psychologists or psychiatrists;

(8) Diagnostic pathology and laboratory services;
(9) Radiology services; and

(10) Hospital, outpatient surgery, and emergency care services.
(F) The WC/MCO must submit sample copies of all types of agreements with providers who will deliver services under the WC/MCO and a description of any other relationships with providers who may deliver services to a covered employee.

(G) The WC/MCO must attach to each type of sample agreement a corresponding list of names, clinics, addresses and types of license and specialties for the health care providers with whom they have utilized the agreement.

(H) In all agreements with the WC/MCO and any other provider of services, the agreement shall contain the following provision: "It is the intent of the parties to this agreement to insure quality services that meet all uniform treatment standards required by Georgia law, and any provision herein which may be inconsistent with that intent shall be void."
(I) The WC/MCO must submit a statement certifying that all licensing requirements for the providers and medical case managers are current and in good standing in Georgia or the state in which the provider is practicing.

(J) The WC/MCO must provide a referral for specialty services that are not specified in subparagraph (E) and that may be reasonable and necessary to effect a cure or give relief as required under O.C.G.A. § 34-9-200. The employer or the workers' compensation insurance carrier remains liable for any health service required under the Workers' Compensation Act, provided that the services meet all other requirements of the Workers' Compensation Act.

(K) The WC/MCO must include procedures to insure that employees will receive services in accordance with the following criteria:
(i) The medical case manager shall inform the employee of his right to choose from the providers designated in Rule 208(a)(1)(E), inform the employee that a list of medical providers is available and provide assistance in obtaining the list if necessary. The medical case manager shall assist the employee in choosing a provider appropriate to the injury. The physician so chosen shall be deemed the "authorized treating physician" for all purposes under the Workers' Compensation Act. Employees must be allowed to change authorized treating physicians within the managed care plan at least once without proceeding through the managed care plan's dispute resolution process. In such cases, employees shall give notice to the manage care plan for a change in their authorized treating physician;

(ii) Employees must be able to receive information on a 24-hour basis regarding the availability of necessary medical services available within the managed care plan. The information may be provided through recorded toll-free telephone messages after normal working hours. The message must include information on how the employee can obtain emergency services or other urgently needed care and how the employee can access an evaluation within a reasonable time after request;
(iii) Employees must receive initial evaluation by a participating licensed health care provider within twenty-four hours after the employee's request for treatment, following a work-related injury;

(iv) In cases where the employee has received treatment for the work injury by a health care provider outside the managed care plan, the employee must receive initial evaluation or treatment by a participating health care provider within five (5) working days of the employee's request for a change of doctor or referral to the managed care plan;
(v) Employees must receive any necessary treatment, diagnostic tests or specialty services in a manner that is timely, effective and convenient for the employee, and reasonable under the circumstances;

(vi) Employees must have reasonable access to health care providers. If the employee is medically unable to travel to a participating provider, the managed care plan shall refer the employee to an available or non-participating provider to receive necessary treatment for the injury.
(L) The WC/MCO must designate the procedures for approval of services from a health care provider outside the managed care plan.

(M) The WC/MCO must include a procedure for peer review and utilization, consistent with Rule 208(g).

(N) The WC/MCO must include a procedure for internal dispute resolution, including a method to resolve complaints by injured employees, medical providers, employers and insurers.
(O) The WC/MCO must inform employees of all choices of medical services provided within the plan and how employees can gain access to those providers including but not limited to a wallet-sized card containing this information in a format suitable for carrying on the employee's person. The plan must submit a proposed publication which may be customized according to the needs of the employer, but must include the information required in Rule 201(a)(3) and must also include a complete list of all WC/MCO medical providers in the applicable geographical service area. All employees of covered employers shall be provided with the publication.

(P) The WC/MCO must provide the information required by Rule 208(h) and describe how medical case management will be provided for injured employees, and an effective program for return-to-work and cooperative efforts by the employees, the employer and the managed care plan to promote workplace health and safety and other services.

(Q) The WC/MCO must provide such other information as the Board considers necessary to determine compliance with the Workers' Compensation Act.
(2) Within 60 days of receipt of an application, the Board must notify an applicant for certification of any additional information required or modification that must be made. The Board must notify the applicant in writing of the approval or denial of certification within 60 days of receipt of the additional information or modification. If certification is denied, the applicant must be provided, in writing, with the reason or reasons for the denial.

(3) Any person aggrieved by a denial of certification by the Board may make written request for a hearing within 30 days of the date the denial is served and filed. The Appellate Division shall hold all hearings and issue a final decision.
(b) Coverage responsibility of WC/MCO.
(1) A WC/MCO must contract with the employer or the workers' compensation insurer of an employer. In the event multiple WC/MCO's are contracted to cover the same employer, each employee shall have the initial election of the WC/MCO that will manage the employee's care, and utilization of a WC/MCO will be deemed an election.

(2) An employee who gives notice to an employer of a compensable injury shall receive medical services in the manner prescribed by the terms and conditions of the WC/MCO contract in effect at the time medical services are rendered.

(3) To insure continuity of care, the WC/MCO contract shall specify the manner in which an injured employee will receive medical services when a WC/MCO contract or contract with the health care provider terminates. The employee may continue to treat with the health care provider or the WC/MCO under the terminating contract until such time as the employee elects to utilize the employer's current posted panel of physicians, conformed panel of physicians or WC/MCO, or a change of physician is granted.
(c) Reporting requirements for Board certified WC/MCO's.
(1) A WC/MCO shall provide the Board with a copy of the following contracts:
(A) Contracts between the WC/MCO and any employer or workers' compensation insurer, prior to utilization of the contract. If the Board does not issue a written approval or denial within 90 days, then the contract shall be approved. Any contract rejected by the Board shall be deemed void for purposes of this Rule. Standard contracts may be submitted instead of individual contracts if no modifications are made. Standard contracts must include a list of signatories and a listing of all employers covered by each contract, including the employers' name, business address and estimated number of employees governed by the WC/MCO. Amendments and addendums to the contracts must be submitted to the Board within 30 days of execution. Contract provisions must be consistent with O.C.G.A. § 34-9-208 and this Rule. The contract must specify the billing and payment procedures and how the medical case management and return-to-work functions will be coordinated.

(B) New types of agreements between participating health care providers and the WC/MCO that are not identical to the agreements previously submitted to the Board shall not be effective until approved by the Board. Any contract which is neither approved nor rejected by the Board within 90 days from submission shall be deemed approved.
(C) Contracts between the WC/MCO and any entity, other than individual participating providers that performs some of the functions of the WC/MCO.
(D) Any changes in the individuals or information required by Board Rule 208(a)(1)(B)(1)-(5).
(2) In order to maintain certification, each WC/MCO shall provide on the first working day following each anniversary of certification the following information in the form of a certified annual report:
(A) A current listing of all individuals identified in Board Rule 208(a)(1)(B)(1)-(5) and all participating health care providers, including provider names, types of license, specialty, business address, telephone number and a statement that all licenses are current and in good standing;

(B) A summary of any sanctions or punitive actions taken by the WC/MCO against any participating providers;

(C) A report that summarizes peer review, utilization review, supplier profiles, reported complaints and dispute resolution proceedings showing cases reviewed, issues involved, and any action taken; and

(D) An audited financial statement for the most recent fiscal year, upon request of the Board.

(E) The annual report must be accompanied by a non-refundable fee of $500.00.
(3) Any proposed changes to the Board certified WC/MCO falling within the categories enumerated below, other than changes to the health care provider list, may not be implemented under the plan until approved by the Board:
(A) Amendments to any contract with participating health care providers;

(B) Amendments to contracts between the WC/MCO and another entity performing functions of the managed care plan; and

(C) Any other amendments to the WC/MCO as certified.
(4) The WC/MCO must report to the employer or insurer any data regarding medical services and suppliers related to the workers' compensation claim required by the self-insured employer or insurer to determine compensability under the Workers' Compensation Act, and any other data required by the Board. The Board may require additional information from the managed care organization if the information is relevant to the Workers' Compensation Act.
(d) Commencement and termination of contract between the WC/MCO and participating providers.
(1) Prospective new participating health care providers under a WC/MCO shall submit an application to the WC/MCO. A director, executive director or administrator may approve the application under the requirements of the WC/MCO. The managed care plan shall verify that each new participating health care provider meets all licensing, registration and certification requirements necessary to practice in Georgia or other applicable state of practice.

(2) A participating provider may elect to terminate participation in the WC/MCO or to be subject to cancellation by the managed care plan under the requirements of the managed care plan. Upon termination of a provider contract, the managed care plan shall make alternate arrangements to provide continuing medical services for an affected injured employee under the plan in compliance with Board Rule 208(b)(3).
(e) A health care provider who is not a participating health care provider may provide medical services to an employee covered by a WC/MCO in any other circumstances provided below:
(1) Emergency treatment;

(2) When the employee is referred to the provider by the managed care organization;

(3) By order of the Board, or by consent of the parties.
(f) Disputes which arise on an issue related to managed care shall first be processed without charge through the dispute resolution process of the WC/MCO. The WC/MCO dispute resolution process must be completed within 30 days of a written notice. If the dispute cannot be resolved, the WC/MCO must immediately notify the employer or insurer. If the dispute involves treatment/test prescribed by the authorized treating physician, the employer or insurer must follow the procedure outlined in Rule 205.

(g) Utilization review and peer review.
(1) The WC/MCO must implement a system for peer review to improve patient care and cost effectiveness of treatment. Peer review must include a majority of health care providers of the same discipline being reviewed. The peer review must be designed to evaluate the quality of care given by a health care provider to a patient or patients. The plan must describe in its application for certification how the providers will be selected for review, the nature of the review and how the results will be used.

(2) The WC/MCO must implement a plan for utilization review. The program must profile each medical supplier and include the collection, review, analysis of group data (utilizing CPT-4 codes) to improve overall quality of care, efficient use of resources and duration of disability. In its application for certification, the WC/MCO must specify the data that will be collected, how the data will be analyzed and how the results will be applied to improve patient care and increase cost effectiveness of treatment.
(h) Medical case management.
(1) The medical case manager must monitor, evaluate and coordinate the delivery of quality, cost effective medical treatment and other health services needed by an injured employee, and must promote an appropriate, prompt return to work. Medical case managers must facilitate communication between the employee, employee's representative, employer, employer's representative, insurer, health care provider, WC/MCO and, when authorized, any qualified rehabilitation consultant to achieve these goals. The WC/MCO must describe in its application for certification how injured employees will be subject to case management, the services to be provided, and who will provide services.

(2) Case management for an employee covered by a WC/MCO must be provided by a licensed registered health care professional holding one of the following certifications: Certified Rehabilitation Registered Nurse (CRRN), Certified Case Manager (CCM), Certified Occupational Health Nurse (COHN), Certified Occupation Health Nurse Specialist (COHN-S), Certified Disability Management Specialist (CDMS), Certified Rehabilitation Counselor (CRC), Work Adjustment/Vocational Evaluation Specialist (WAVES), or Licensed Professional Counselor (LPC). Case managers must have at least one year experience in workers' compensation. In catastrophic cases, case management must include assignment to a Board-registered rehabilitation supplier, who has been designated by the board as qualified to manage catastrophic cases (Rule 200.1(f)(4)). If qualified, the case manager may register with the Board to serve as the catastrophic rehabilitation supplier.
(3) The parties to the claim and their representatives shall cooperate with medical case management services when such services are being provided by a WC/MCO which has been certified pursuant to O.C.G.A. § 34-9-208 and Board Rule 208 and which has posted a WC-P3 panel. The unreasonable refusal to cooperate with or the unreasonable interference with medical case management services by any party or its representative may subject that party or its representative to civil penalties pursuant to O.C.G.A. § 34-9-18. The employer/insurer may suspend weekly benefits for the failure of the employee to cooperate with medical case management only by order of the Board.
(i) Monitoring records.
(1) The Board shall monitor and may conduct audits and special examinations of the WC/MCO as necessary to insure compliance with the WC/MCO certification and performance requirements.

(2) All records of the WC/MCO and its participating health care providers relevant to determining compliance with the Workers' Compensation Act shall be disclosed in a reasonable time after request by the Board. Records must be legible and cannot be kept in a coded or semi-coded manner unless a ledger is provided for codes.

(3) The release of records filed with the Board must clearly identify the portions of the application or records which are believed to be non-public trade secret data or otherwise confidential.
(j) Suspension; revocation.
(1) The WC/MCO shall work with all parties and their representatives in a reasonable manner consistent with the purposes of this Act. Complaints pertaining to violations by the WC/MCO shall be directed in writing to the Board. Upon receipt of a written complaint or after monitoring the managed care plan operation, the Board shall investigate the alleged violation. The investigation may include, but shall not be limited to, requests for and review of pertinent managed care records. If the investigation reveals reasonable cause to believe that there has been a violation warranting suspension or revocation of certification, the Board shall schedule a hearing.

(2) The certification of any WC/MCO issued by the Board may be suspended or revoked, in the discretion of the Board, if the WC/MCO fails to meet any of the requirements of O.C.G.A. § 34-9-208 or Board Rule 208.

(3) For purposes of this Rule, "suspension" and its variations means the cessation of the WC/MCO's authority to enter into new contracts with employers or insurers for a specified period of time up to a maximum of one (1) year. Upon suspension, the WC/MCO may continue to provide services in accordance with the contracts in effect at the time of the suspension. A suspension may be set aside prior to the end of the designated suspension period if it is shown to the satisfaction of the Board that the WC/MCO is in compliance. Furthermore, if it is shown that the WC/MCO is not in compliance immediately prior to the end of the designated suspension period, the suspension may be extended without further hearing, or revocation proceedings may be initiated.

(4) For purposes of this Rule, "revocation" and its variations means a revocation of a WC/MCO's certification to provide services under these Rules. If the WC/MCO certification is revoked, no employee is covered by the contract between the WC/MCO and the employer or workers' compensation carrier. However, upon revocation of certification, the WC/MCO may continue to provide services under contracts in effect to the extent the Board determines that it is necessary for injured employees to continue to receive medical services in that manner.
(5) Suspension or revocation under this Rule will not be made until the WC/MCO has been given notice and the opportunity to be heard through a show-cause hearing before the Board. The Board shall provide the WC/MCO written notice of an intent to suspend or revoke the WC/MCO's certification and the grounds for such action. The notice shall also advise the WC/MCO of the right to participate in the show-cause hearing and specify the date, time and place of the hearing. The notice shall be issued from the Board at least twenty-one (21) days prior to the scheduled date of the hearing. After the show-cause hearing, the Board may issue a final order suspending or revoking the WC/MCO's certification.

(6) Upon revocation of a WC/MCO's certification, the employer or the workers' compensation insurer of an employer with whom the revoked WC/MCO had been contracted to provide managed care shall make alternate arrangements to provide continuing medical services for injured employees who had been receiving medical care through the revoked WC/MCO. Any injured employee receiving medical services through a WC/MCO prior to revocation of the WC/MCO's certification may continue to treat with one of the individual health care providers with whom the employee had received medical services prior to revocation until such time as the employee elects to utilize the employer's replacement posted panel of physicians, conformed panel of physicians or WC/MCO, or a change of physician is ordered.
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Board Rule 61(b)(28). Form WC-200a. Change of Physician/Additional Treatment by Consent

Parties who agree on a change of physician/additional treatment shall file a properly executed Form WC-200a with the Board, with copies provided to the named medical provider(s) and parties to the claim, which form shall be deemed to be approved and made the order of the Board pursuant to O.C.G.A. §  34-90-200(b) unless otherwise ordered by the Board.  A Form WC-200a shall be rejected by the Board if a Form WC-1 or WC-14 has not been previously filed by any party or attorney creating a Board claim.

  • Form WC-200a/Change of Physician/Additional Treatment by Consent

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Board Rule 61(b)(29). Form WC-200b. Request/Objection for Change of Physician/Additional Treatment

A party who requests a change of physician or additional treatment without consent, or who objects to a request which has been made, shall file this form with the Board, and serve a copy on all counsel and unrepresented parties.  Objections must be filed within 15 days of the date on the certificate of service on the request.

  • Form WC-200b/Request/Objection for Change of Physician/Additional Treatment

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Board Rule 61(b)(30). Form WC-205. Request for Authorization of Treatment or Testing by Authorized Medical Provider

Authorized medical providers seeking approval for treatment or testing shall send this form by facsimile or e-mail directly to the insurer/self-insurer who must fax or e-mail a response within five business days.  Neither the request nor response shall be filed with the Board, unless otherwise requested.

  • Form WC-205/Request for Authorization of Treatment or Testing by Authorized Medical Provider

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Board Rule 61(b)(51). Panel of Physicians

Panel of Physicians.  See Board Rule 201.
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Board Rule 61(b)(52). Form WC-P2. Conformed Panel of Physicians.

See Board Rule 201.

  • WC-P2/Conformed Panel of Physicians

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Board Rule 61(b)(53). Form WC-P3. WC/MCO Panel

To be utilized only by employers/insurers contracted with a Board Certified Managed Care Organization.  See Board Rule 201.

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Board Rule 61(b)(54). Form WC-Bill of Rights. Bill of Rights

Use and post with the panel of physicians (Form WC-P1, Form WC-P2, or Form WC-P3).  See O.C.G.A. § 34-9-81.1 & Board Rule 81.1.

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O.C.G.A. § 34-9-201. Selection of physician from panel of physicians; change of physician or treatment; liability of employer for failure to maintain panel

(a)  As used in this Code section, the term "physician" shall include any person licensed to practice a healing art and any remedial treatment and care in the State of Georgia.

(b)  The employer may satisfy the requirements for furnishing medical care under Code Section 34-9-200 in one of the following manners:

(1)  The employer shall maintain a list of at least six physicians or professional associations or corporations of physicians who are reasonably accessible to the employees; provided, however, that the board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians or groups of physicians are not reasonably accessible.  This list shall be known as the "Panel of Physicians."  At least one of the physicians must practice the specialty of orthopedic surgery.  Not more than two industrial clinics shall be included on the panel.  An employee may accept the services of a physician selected by the employer from the panel or may select another physician from the panel.  The physicians selected under this subsection from the panel may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require without prior authorization from the board; provided, however, that any medical practitioner providing services as arranged by a primary authorized treating physician under this subsection shall not be permitted to arrange for any additional referrals.  The employee may make one change from one physician to another on the same panel without prior authorization of the board;

(2)  The employer may maintain a list of physicians in conformity with the guidelines and criteria established and contained in the Rules and Regulations of the State Board of Workers' Compensation.  This list shall be known as the "Conformed Panel of Physicians."  An employee may obtain the services of any physician from the conformed panel and may thereafter also elect to change to another physician on the panel without prior authorization of the board.  The physician so selected will then become the primary authorized treating physician in control of the employee's medical care and may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require without prior authorization by the board; provided, however, that any of the physicians to whom the employee is referred by the primary authorized treating physician shall not be permitted to arrange for any additional referrals; or

(3)  A self-insured employer or the workers' compensation insurer of an employer may contract with a managed care organization certified pursuant to Code Section 34-9-208 for medical services required by this chapter to be provided to injured employees.  Medical services provided under this paragraph shall be known as "Managed Care Organization Procedures."  Those employees who are subject to the contract shall receive medical services in the manner prescribed in the contract. Each such contract must comply with the certification standards provided in Code Section 34-9-208.  Self-insured employers or workers' compensation insurers who contract with a managed care organization for medical services shall give notice to the employees of the eligible medical service providers and such other information regarding the contract and manner of receiving medical services as the board may prescribe.

(c)  Consistent with the method elected under subsection (b) of this Code section, the employer shall post the Panel of Physicians or Conformed Panel of Physicians or Managed Care Organization Procedures in prominent places upon the business premises and otherwise take all reasonable measures to ensure that employees:

(1)  Understand the function of the panel or managed care organization procedures and the employee's right to select a physician therefrom in case of injury; and

(2)  Are given appropriate assistance in contacting panel or managed care organization members when necessary.

(d)  Notwithstanding the other provisions contained in this Code section, if an inability to make a selection of a physician as prescribed in this Code section is the result of an emergency or similarly justifiable reason, the selection requirements of this Code section shall not apply as long as such inability persists.

(e)  Upon the request of an employee or an employer, or upon its own motion, the board may order a change of physician or treatment as provided under Code Section 34-9-200.

(f)  If the employer fails to provide any of the procedures for selection of physicians as set forth in subsection (c) of this Code section, an employee may select any physician to render service at the expense of the employer.

(g)  The board shall promulgate rules and regulations to ensure, whenever feasible, the participation of minority physicians on panels of physicians maintained by employers or in managed care organizations pursuant to this Code section.

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O.C.G.A. § 34-9-206. Reimbursement for costs of medical treatment

(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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O.C.G.A. § 34-9-310. Resolution of medical questions resulting from claims for compensation

(a)  When medical questions are in controversy in any claim for compensation for an occupational disease, the parties may agree to refer the employee to a licensed physician specializing in the diagnosis and treatment of the disease at issue for an independent medical examination and report.  In the event that the parties cannot agree on the referral to be made, the State Board of Workers' Compensation shall refer the employee to a licensed physician who specializes in diagnosis and treatment of the disease at issue and who is certified by the appropriate medical board in the field encompassing such disease for an independent medical examination and report. No award may be made in such case until the appointed physician has filed with the board the report respecting all medical questions at issue.  The date of disablement, if in dispute, shall be deemed a medical question.  The board is authorized to charge the expense of the independent medical examination and report against either or both parties in the final award.

(b)  Proceedings may be suspended and no compensation may be payable for any period during which the employee may unreasonably fail or refuse to submit to such an examination.

(c)  Upon the filing of a claim for compensation for death from an occupational disease where an autopsy is necessary to accurately and scientifically ascertain or determine the cause of death, such autopsy may be ordered by the board.  The board may specify and designate a licensed physician who is a specialist in such examinations and who is certified by the appropriate medical board in the field encompassing such disease to perform or attend the autopsy and to certify his or her findings thereon.  Such findings shall be filed with the State Board of Workers' Compensation and shall become a part of the record in the case.  In the event no claim has been filed, the board may exercise such authority on its own motion or on application made at any time, upon presentation of facts showing that a controversy may arise in regard to the cause of death or the existence of any occupational disease.  The board is authorized to charge the expense of any such autopsy against the party requesting it.

(d)  The physician selected to conduct the independent medical examination of the claimant, and to issue a report on all medical questions presented, shall report in writing and file with the board all findings and conclusions on every medical question in controversy as soon as practicable, but in any event no later than 60 days after the date on which the independent medical examination, or autopsy, has been completed.

(e)  Either party may submit information to and may cross-examine such physician in accordance with paragraph (2) of subsection (e) of Code Section 34-9-102.  Each party submitting information to such physician shall serve a copy of such information to the opposing party.  The findings and conclusions contained in such report or testimony of such physician shall create a presumption of the correctness of such findings and conclusions, which presumption may be rebutted by other competent medical evidence.

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