California Professional Forums - MPN-Denied claim

HOME PAGE

GO to Injured Worker Forum

Navigation:

login

ALL FORUM'S TOPICS OR UR, MPN & ACOEM TOPICS

Thread Title: MPN-Denied claim
Created On Thursday June 26, 2008 2:04 PM

NADdmecollector
Member

Posts: 87
Joined: May 2007

Thursday June 26, 2008 2:04 PM

User is offline

View thread in raw text format

If IC denies claim 100%, is there grounds for objection to Tx based on MPN regulations? Seems to me that if the claim is denied, they can't reasonably force IW to seek Tx within the MPN since they have denied that there was valid workplace injury.

-------------------------
S.A. Schoenkopf

gaiassoul1@yahoo.com
Senior Member

Posts: 1275
Joined: Feb 2004

Thursday June 26, 2008 2:10 PM

User is offline

View thread in raw text format

sure they can in the event they do not prevail on their denial of the case in chief, then they would be liable for the medical care provided and the reason for the MPNs was to promote cost savings -- so if they have met the notification requirements in dotting their i's and crossing their t's as outlined in Knight vs. UPS, then they have a right to assert an MPN until the AOE/COE issues are resolved.

And I have not seen that many carriers ante up all of the necessary documentation as to the MPN notifications.

How many injuries have we seen become compensable once the medical-legal process is complete at that point or simultaneousy until all disputes are resolved they can assert all applicable issues.

NADdmecollector
Member

Posts: 87
Joined: May 2007

Thursday June 26, 2008 2:51 PM

User is offline

View thread in raw text format

Thank you, Ginger. Yet isn't that putting the trailer before the horse? On the one hand they denied the claim. I don't think they denied the claim thinking "Well, we will deny it now, but it may/will become compensable later." Just as they refuse to put Tx requests through UR to determine the medical neccesity based on the injury on a denied claim and just deny authorization "since the claim is denied, all Tx is denied;" if they deny that there is an injury AOE/COE, how would it be saving costs by forcing Tx within the MPN, if the claim is later found to non-compensable? Do the MPN Doctors then have to refund what they got paid for treating a non-industrial injury? If all the Tx is not necessary, how is the MPN Tx determined to be ok?

I agree that I have rarely seen IC produce the necessary documentation regarding notification, although in the last year or so, they have become more cognizant of what constitues proper notification.

-------------------------
S.A. Schoenkopf

Edited: Thursday June 26, 2008 at 2:59 PM by NADdmecollector

gaiassoul1@yahoo.com
Senior Member

Posts: 1275
Joined: Feb 2004

Thursday June 26, 2008 3:00 PM

User is offline

View thread in raw text format

have no idea as to the refund idea, not sure that the MPN would even treat on a lien, but if they don't then that would be justification to step outside of the MPN.

Think carriers are beyond stupid for not utlizing UR on denied cases, they risk a lot by not doing so timely, just my humble opinion - because the UR could read - if applicant prevails on AOE/COE, then treatment is certified or non-certified based on other rationale.

Rarely see an adjuster plotting plan B on denied claims, hell you rarely see them pick up the AME report and pay past bills when they decide to accept a claim? but then again that would require common sense, which is a gift and is not common.

NADdmecollector
Member

Posts: 87
Joined: May 2007

Thursday June 26, 2008 3:13 PM

User is offline

View thread in raw text format

Yes, my facility on a daily basis gets denied authorization by the adjuster who refused to put through UR just due to denied claim, which is as you say, beyond stupid. Down the road, when there is compensabilty found, now they have less standing to argue reasonable/necessary or ACOEM/MTUS since they never sent it through UR to make such determination. Well thank you for your input, Ginger.

-------------------------
S.A. Schoenkopf

jonbrissman@verizon.net
Senior Member

Posts: 377
Joined: Oct 2003

Thursday June 26, 2008 6:20 PM

User is offline

View thread in raw text format

I find no authority supporting the notion that defendant has any medical control on a denied claim. If a claimant self-procures treatment on a denied claim and the claim is later accepted or found to be compensable, the consequences to defendant are liability for out-of-network treatment, interest from the time the bills became due, inability to raise the "treatment requires preauthorization" defense, a 15% increase if there was no timely and adequate objection letter(s), inability to use retroactive UR in some cases, etc.

Since 90% of the cases initially denied are later accepted (according to Dept. of Insurance research), and since treatment costs on those initially-denied cases likely are substantially greater than costs on accepted claims, it could make economic sense for carriers/employers/TPAs to accept all claims initially, channel the claimants into their MPNs, and crank up the UR apparatus. The added benefit of the accept-all-claims strategy is no exposure under LC 5402 to the first $10K in treatment costs.

Geez, why do I start writing on one topic and then morph into another?

JCB

gaiassoul1@yahoo.com
Senior Member

Posts: 1275
Joined: Feb 2004

Thursday June 26, 2008 7:22 PM

User is offline

View thread in raw text format

it would be interesting to see the cost of a typical type of injury such as a back strain/sprain in an MPN vs. the cost of the liens, since accepting benefits is not an admission of liablity providing the medical care vs. resolving the liens could potentially be more cost effective, especially with the cost controls in place for the MPN.

stewshe@comcast.net
Senior Member

Posts: 1381
Joined: Jun 2002

Saturday June 28, 2008 6:33 PM

User is offline

View thread in raw text format

All,

I have seen 1 or 2 defendants who are providing medication payment cards on ALL litigated claims. They provide RXs...even on denied claims!

Why?

Because it saves them money in the long run! Not all def's are "Penny wise, pound foolish!"

Gives me fits trying to explain to EEs why a defendant would give them a card to use to get meds when their bills to doctors and transportation to the pharmacy are not paid!

They do it because of the steep discounts they get and the knowledge they have concerning the number of claims they have and how often they manage to get a "take nothing." In the long run, they avoid liens, penalties, interest, and the EE gets Rxs needed, even in denied claims, which is admittedly strange!

I agree, once a Def denies a claim, refusing to pay medical bills, they lose medical control, including MPNs. The EE has the right to self-procure with whomever will treat them. The classic case is the old "Duke University" claim where weight loss was prescribed, defendant did nothing in the face of requests for treatment, so the EE self-procured treatment from the most expensive facility in the country at Duke University.

Rbursement was ordered including meals, mileage, and the cost of accomodations. See Braewood Convalescent Hospital vs WCAB (Bolton) 11 CWCR 163, 190, 48 CCC 566.....Supreme Court as I recall. A lengthy, well reasoned decision showing the danger to a defendant in ignoring a request for treatment! It can get expensive!

-------------------------
Stew (James T. Stewart) e-mail: stewshe@comcast.net
Author: Work Comp Index & Tables & Schedules in "The Labor Code Book," by LexisNexis/Matthew Bender.

7th ed. Work Comp Index (912 pgs), $119.00 ea; next ed. summer, 2010 {Discounts for orders of 12 or more}
Send check or money order & shipping info. (I cannot take credit cards.)

Prices INCLUDE sales tax, and shipping.

James T. Stewart; 1937 Santa Ana; Clovis, CA 93611

FORUMS > UR, MPN & ACOEM

FuseTalk 3.0 - Copyright © 1999-2002 e-Zone Media Inc. All rights reserved.

© 2013 WorkCompCentral Workers Compensation Forums