Carrier is able to question generic referrals without incurring risk of penalties.
Colorado Workers’ Compensation Law prohibits employers, claimants, and insurers from dictating medical care.
Employers, insurers, claimants, or their representatives shall not dictate to any physician the type or duration of treatment or degree of physical impairment. Nothing in this subsection (3) shall be construed to abrogate any managed care or cost containment measures authorized in articles 40 to 47 of this title. CRS §8-43-503(3)
When Ms. Teagarden’s authorized treating physician, Dr. Pak, wrote a generic referral for her to treat with primary care physician for prescription refills, the carrier asked for clarification. The letter – addressed to “Whom it may Concern” – did not identify a specific doctor, did not state what body part was to be treated, explain the medical necessity of the treatment, and was written thirteen months since the last examination had occurred.
The insurance carrier filed an application for hearing on the issue of medical benefits, and also sent a letter asking Dr. Pak to clarify the letter. After a hearing on the medical benefits (which were awarded) Ms. Teagarden sought penalties for dictation of care.
The Administrative Law Judge (ALJ) denied the claim for penalties ruling that it had acted reasonably given the ambiguity over the identity, treatment, and body parts covered in the referral.
As always, how this or any other case we discuss in this blog would apply to your case depends on many more factors. We urge you to call us to see if you are entitled to workers’ compensation benefits. Workers’ Compensation is difficult, confusing, and very complex. Kaplan Morrell, a Denver workers compensation law firm, has helped thousands of injured workers since 1997 get the benefits they deserve. Contact us here or call us at 303-780-7329 for your FREE CONSULTATION.
Cite: Chun Cha Teagarden v. JC Penny, (WC No. 4-748-106, January 13, 2014)
Tags: Penalties, Dictation of Care, Authorization, Medical Benefits