WC Medical Fee Disputes
The procedure for Workers Comp medical provider fee disputes has changed. You can find the link here or the new rules are published below. You will need a PDF reader to view the document. You can also print this blog post. I tried to make the new rules as readable as possible. Some web browsers may change or scramble it.
My main concern is the 20 day deadline for the 26I response by a carrier, TPA, or employer. Are the 20 days from receipt or when the dispute was mailed by the provider?
Procedure for Medical Provider Fee Dispute Resolution Pursuant to N.C. GEN. STAT. §97-26(i)
1. Direct Inquiry
A Medical Provider may submit an Industrial Commission Form 26I: Medical Provider Dispute Resolution Questionnaire directly to the employer or carrier believed to be liable for unpaid medical fees.
a. The Medical Provider will be responsible for obtaining directly from the injured employee information regarding the identity of the employer liable for the injury.
b. The Medical Provider may obtain contact information for an employer, or for the workers’ compensation insurance carrier for a particular employer on a particular injury date, by means of the Workers’ Compensation Name Search System on the Industrial Commission website.
c. If the Medical Provider is unable to obtain the necessary employer or carrier contact information through the Workers’ Compensation Name Search System, the Medical Provider may contact the Medical Fees Section of the Industrial Commission for assistance in obtaining that carrier contact information.
i. The assistance provided by the Medical Fees Section will be
limited to providing employer contact information and to assisting
the Medical Provider in identifying the workers’ compensation
insurance carrier associated with a particular employer on a particular date.
ii. The Medical Fees Section will not share with the Medical Provider
any information related to any specific claim before the Industrial
Commission.
iii. The Medical Fees Section will not directly facilitate or otherwise
be involved in any communication between the Medical Provider and any employer or workers’ compensation insurance carrier at this stage in the process.
2. Informal Dispute Resolution Process
If the employer or carrier does not respond to the Form 26I Questionnaire within 20 days or responds by denying liability for the unpaid medical fees, the Medical Provider may submit a written request for assistance to the Medical Fees Section of the Industrial Commission. The written request for assistance must be accompanied by a copy of the Form 26I Questionnaire submitted by the Medical Provider, including all accompanying materials, and any response received by the Medical Provider from the employer or carrier contacted. Upon receipt of the written request for assistance meeting the above requirements, the Medical Fees Section will initiate an informal dispute resolution process between the Medical Provider and the employer or carrier identified on the Form 26I Questionnaire.
3. Limited Intervention
If informal dispute resolution does not resolve the dispute to the Medical Provider’s satisfaction, the Medical Provider may request limited intervention in an existing claim before the Industrial Commission by filing a formal Motion to Intervene with the Executive Secretary’s Office. The motion will be granted only if (a) a claim related to the medical fees in dispute has been filed before the Industrial Commission, and (b) liability for the underlying injury in the claim has not been denied or has been adjudicated in the employee’s favor.
The Motion to Intervene must include the following:
a. IC file number, if known.
b. Employee’s name, address, and SSN (last four digits only).
c. Date of injury and a brief description of the workplace injury, including the body parts known to be affected.
d. Itemized list of the medical fees in dispute, including CPT codes relating specific charges to the Workers’ Compensation Medical Fee Schedule, and explanations directly relating each charge to the employee’s workplace injury.
e. Copy of the Form 26I Medical Provider Dispute Resolution Questionnaire submitted by the Medical Provider, including all accompanying materials, and any response received back by the Medical Provider from the employer or carrier contacted.
f. Copy of the written request for assistance submitted to the Medical Fees Section.
g. Copy of the written summary by the Medical Fees Section of the informal resolution process and outcome.
h. Sworn affidavit by the Medical Provider that:
i. The Medical Provider has treated the employee,
ii. The medical fees itemized by the Medical Provider are current and unpaid, and
iii. The Medical Provider reasonably believes that the employer or carrier named on the Form 26I Questionnaire is obligated to pay the fees under the Workers’ Compensation Act.
i. Certification of service upon both the employee and the employer or carrier named on the Form 26I Questionnaire.
4. Request for Review by the Full Commission of a Denial by the Executive Secretary
If the Medical Provider’s request to intervene is denied by the Executive Secretary, the Medical Provider may request the Full Commission’s administrative review of the Executive Secretary’s Order, by filing such written request with the Dockets Section within 10 days of receipt of the Executive Secretary’s Order denying the intervention. The request for review by the Full Commission must be served on all parties and must be accompanied by a statement of facts necessary to an understanding of the issue; a statement of the relief sought; copies of the motion to intervene with all attachments as required by Section 3 of this procedure which was submitted for consideration by the Executive Secretary; and a copy of the Order denying the motion to intervene.
Within 10 days after service of the request for review by the Full Commission, any other party to the case may file a response with supporting affidavits or related portions of the file that were not submitted with the request for review by the Full Commission.
A determination will be made by the Full Commission on the basis of the request for review, any response, and any supporting documents. No briefs or oral argument will be received or allowed unless ordered by the Industrial Commission upon its own motion.
5. Discovery and File Requests
If the Medical Provider is allowed to intervene, the Medical Provider shall have limited access only to those elements of the claim file related to the medical fee dispute, in accordance with the non-public nature of the claim file under N.C. GEN. STAT. § 97-92(b). Requests for information from the Industrial Commission file related to the medical fee dispute must be in writing and directed to the Claims Section of the Industrial Commission and accompanied by the Executive Secretary’s Order allowing the Medical Provider to intervene. Discovery, as to the matters related to the medical fee dispute, may be conducted by the Medical Provider once the Medical Provider has been allowed to intervene.
6. Request for Hearing
An intervening Medical Provider may request a hearing before the Industrial Commission on the fee dispute by filing an Industrial Commission Form 33I: Intervenor’s Request that Claim be Assigned for Hearing along with a $200.00 filing fee. The Form 33I will be handled in the same manner as a Form 33 Request for Hearing, including referral to mediation through the Mediation Section.
Upon resolution of the fee dispute, whether by agreement of the parties or decision of the Industrial Commission, the Medical Provider will be dismissed from the claim. Thereafter, the only standing the Medical Provider will retain in the claim following an Order.
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