Matt Lewis Law - Collection Strategies For Liability Medical Necessity Disputes Feb 2011

1. Collection Strategies For Providers Faced With Liability & Medical Necessity Disputes - 2011 • Matt Lewis • Rogers, Booker & Lewis • matt.lewis@dallasworkcomp.com

2. New IR Distribution Requirements • Effective March 1, 2011 • New DWC-69 • DWC-69 and narrative must be faxed to Austin Central at (512) 490-1047 • Designated Doctors must also fax DWC-73

3. Liability Disputes • Compensability • Extent Of Injury • Entitlement To Benefits

4. New DD Rules Provide Collections Stick • Effective February 1, 2011 • Carrier shall pay all benefits, including medical benefits, in accordance with the DD report • Upon receipt of DD report, carrier has 21 days to pay medical benefits

5. Carrier must reprocess all medical bills previously denied for reasons inconsistent with the findings of the DD • Rule 127.10(h)

6. What To Do: • Fax a copy of the favorable DD report to the adjuster and keep the fax receipt • Do not make a demand for payment or otherwise prompt the adjuster to quickly initiate dispute resolution • Wait 21 days • Demand payment immediately and file complaint against carrier and adjuster with DWC for failure to timely pay a medical bill

7. Sub-Claims • Establish sub-claimant status by showing a benefit was delivered and reimbursement was denied (a bill and an EOB) • Providers may pursue compensability and extent of injury issues to a benefit review conference

8. If the claimant participates in the dispute resolution process the provider is able to appear and negotiate, give testimony, evidence and argument • If the claimant is not participating, several prerequisites apply (Rule 140.6)

9. Prerequisites • No prior written agreements between the claimant and carrier or DWC decision resolving the dispute • Must give written notice to the claimant

10. Written Notice Of: • Intent to pursue the claim • Warning that the resulting decision could be binding against claimant • Contact info for the OIEC

11. Collect Old Write-Offs! • This method can be used to collect on aged files, many years old • Rule 133.307(c) allows for filing MDR up to 60 days once a related compensability, extent of injury or liability issue is resolved • Great idea for large unpaid bills like chronic pain management or work hardening that were denied as treatment not related to the compensable injury

12. Medical Necessity • Deviating from ODG • IRO process • Medical CCH • Judicial Review

13. Documenting Exceptions To ODG • Appendix D of ODG • First, use the help desk to find the correct section of ODG for the requested treatment • You can actually suggest ODG updates

14. What To Document • Extenuating circumstances that warrant the treatment • Co-morbidities • Objective signs of functional improvement for treatment conducted so far

15. Measurable goals and progress points expected from additional treatment • Any additional supporting evidence

16. Most important criteria are the co-morbidities and documented functional improvement from prior treatment

17. Dispute Process • When preauthorization is denied, must submit request for reconsideration within 15 days • If denied again, IRO request must be filed within 45 days (Form LHL-009) • If IRO is adverse, 20 days to request a CCH • Network appeals go to judicial review

18. Medical CCH Tips • Introduce into evidence all applicable medical records, especially those that address Appendix D deviation requirements • Do not rely only on your own testimony of medical necessity • Offer medical studies and journal articles supporting your position

19. Offer other treatment guidelines that recommend the requested treatment • Play up co-morbidities - they make each patient different from the averages • Provide supporting studies about the effect of the co-morbidity on recovery - do not rely only on your testimony

20. @MatthewBLewis