Treating Providers Limited to 75% Payment For Retroactive Services, When

Effective January 1, 2013, medical providers may be limited to receiving only seventy-five percent (75%) of the applicable fee schedule amount if they provide medical services to an injured worker without first obtaining prior authorization. Moreover, the medical provider is prohibited from "balance billing" the injured worker for the difference. Ohio Admin. Code 4123-6-16.3 states that medical treatment reimbursement requests submitted retroactively "without just cause" shall be reimbursed at 75%. A medical provider is deemed to have acted with just cause under the following circumstances:

* The treatment provided was "emergency treatment";

* The provider was not aware the medical services were for a workers' compensation claim;

* The provider was not BWC certified and had no established relationship with the injured worker;

* The provider had been BWC certified for 6 months or less before providing the medical services;

* The treatment was for a medical condition that was pending before the BWC or Industrial Commission;

* The treatment was within the BWC's presumptive authorization guidelines, or does not require pre authorization;

* The treatment was submitted retroactively because of a BWC or MCO error; or

* The BWC accepts documentation of any other sufficient justification.

See Ohio Adm. Code 4123-6-16.3(B)(1)-(8).

The medical provider may have up to seven (7) calendar days to submit a retroactive request without being subject to the 75% reimbursement provision, but only if the medical provider does not have another treatment encounter with the patient before the 7 days has passed.

For more information about reimbursements for retroactive authorizations of medical treatment in a workers' compensation claim, call us today. 614-221-1300.

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