Employer Not Required to Pay for Services Provided By Unlicensed Provider

The Vermont Department of Labor has ruled an employer/carrier is not responsible for paying for treatment provided by an unlicensed or uncertified provider if Vermont law requires that only a licensed or certified practitioner can provide a particular type of medical service.  Myrick v. Ormond Bushey and Sons, Op. No. 07-14 WC (April 25, 2014).

The workers' compensation statute requires the employer to pay for reasonable medical services caused by a work injury, provided they were "lawfully delivered medical services."  Id. (citing 21 V.S.A. §640). If a practitioner is not required to be licensed or certified to provide treatment under Vermont law, then the employer may be responsible for paying a charge for service.  V.O. Windsor Hospital, Op. No. 12-08 WC (March 27, 2008)(citing 21 V.S.A. §640(a)).

Additionally, the decision reaffirms that an employer is not obligated to to pay charges of a provider who fails to maintain treatment records or submit appropriately documented medical bills.  Myrick v. Ormond Bushey and Sons, Op. No. 07-14 WC (April 25, 2014).

Mileage Reimbursement Reduced to $.56 a Mile

The Department of Labor has announced that effective January 1, 2014 the Workers’ Compensation mileage reimbursement rate will be $.56 per mile. According to the Department's email the mileage reimbursement rate as determined by Rule 12.2100 is for "mileage traveled for medical treatment, to attend an employer's independent medical examination, or attend a vocational rehabilitation meeting, beyond the distance normally traveled to the workplace."  This is a slight reduction from the current rate of $.565. 

 

 

Preathorization of Medical Treatment

At the recent Vermont Workers' Compensation Adjusters' Continuing Education Conference a number of participants had questions regarding pre-authorization under Vermont law.  The statute sets forth time lines and other obligations that are placed on a carrier/employer that receives a written pre-authorization request and supporting documentation.

 

The statute requires that a pre-authorization request must be submitted to the insurer with supporting medical documentation. Within 14 days of receipt of the request the carrier/employer shall either (1) authorize the treatment; (2) deny the treatment with appropriate documentation; or (3) notify the health care provider, the injured worker, and the department that the insurer has scheduled an examination of the employee or ordered a medical record review.  In that event the carrier/employer must notify the department, health care provider and the injured worker within 45 days of the request for pre-authorization of the decision to pre-authorize or not.  21 VSA §640b.

 

The statute is located here:

 

http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=21&Chapter=009&Section=00640b

 

The Director of Workers' Compensation has issued guidance regarding the pre-authorization statute.  Those memorandum are located here:

http://www.labor.vermont.gov/Portals/0/WC/preauthmemo.pdf

http://www.labor.vermont.gov/Portals/0/WC/preauthclarify.pdf

A form providers may choose to use for a pre-authorization request is located at: 

 

http://www.labor.vermont.gov/Portals/0/WC/preauthform.pdf. 

Medical Marijuana Not Required to Be Paid By Workers’ Compensation Carriers

The Vermont legislature recently passed a medical marijuana statute and some providers have prescribed marijuana as part of an injured worker’s treatment plan.  However, it should be noted that the statute itself states, in part, that the law shall not be construed to require that coverage or reimbursement for the use of marijuana for symptom relief be provided by an employer or for purposes of workers' compensation, an employer as defined in 21 V.S.A. § 601(3).  18 V.S.A. § 4474C(b)(3)(4). Additionally, marijuana remains a controlled substance under the Controlled Substances Act.  21 U.S.C. § 811 and § 812.

Employer Ordered to Pay for Medications

The worker suffered a low back injury at work.  The parties subsequently agreed to a settlement that allowed the claimant to continue to receive medically reasonable and necessary treatment that was related to the work injury.  The employer filed for discontinuance of medications based on a records review that concluded the medications were not necessary for treatment of a work-related injury but rather for other personal medical conditions.  The doctor also questioned whether the use of some of the medications, which were being used in “an off-label context,” was medically appropriate.  Perry v. State of Vermont, Op. No. 13-13WC (2013).

The Department of Labor concluded that the employer is responsible only for those medical treatments that are reasonable and causally related to the injury.  Perry v. State of Vermont, Op. No. 13-13WC (2013) (citing 21 V.S.A. §640(a); Baraw v. F.R. Lafayette, Inc., Op. No. 01-10WC (2010); MacAskill v. Kelley Servs., Op. No. 04-09WC (2009)).  Utilizing the commonly cited five factor test, the Department concluded that the claimant’s treating doctor’s opinions as to causality and necessity were more credible than the employer’s doctor’s opinions. Perry v. State of Vermont, Op. No. 13-13WC (2013) (citing Geiger v. Hawk Mountain Inn, Op. No. 37-03 (2003)).  Specifically, the Department cited the fact that the claimant’s expert was a treating physician and that relationship allowed him to: differentiate between the work-related injury symptoms and the symptoms that resulted from personal medical issues; and use trial and error to create a successful pharmacology regime evidence by better pain control, fewer drugs and lower dosages.  Perry v. State of Vermont, Op. No. 13-13WC (2013).  The Department further concluded that the employer’s expert opinion was based on an assumption, rejected by the Department, that the claimant’s personal medical diagnosis excluded all other possible causes for the worker’s pain complaints.  Such reliance rendered his opinion unpersuasive.  Perry v. State of Vermont, Op. No. 13-13WC (2013).

Department of Labor Creates "Health Care Provider Report" Form

The Vermont Department of Labor has created a new form to assist physicians in providing the employer/carrier with information regarding the treatment of an injured worker.  The form is called the “Health Care Provider Report” and is also known as the HCP1. The form is not required to be filed.  The Department describes this as a tool to assist in obtaining relevant medical information regarding workers’ compensation injuries/illnesses. 

The form is a one page document that provides basic information such as: The employee’s name, address, date of birth and phone number; Information regarding the injury itself, such as, the date of the injury, the body part injured, the date of the examination, the diagnosis and whether the injury was work related; A line is provided for documenting test results, interpretation of the results, what medications are prescribed and what the treatment plan is; and there is a section for a brief comment on return to work.

This form is not required.  It does not change the law that requires that any provider seeking reimbursement for services must provide legible, supporting documentation. Vermont Workers’ Compensation Rules, Rule 40.021(C).  That supporting documentation is described as, “documentation for each service provided which is sufficiently detailed to allow for the review of the medical necessity of the service and the appropriateness of the fee charged.” Vermont Workers’ Compensation Rules, Rule 40.021(E).

The link to the new form is:

http://www.labor.vermont.gov/Portals/0/WC/healthcareprovidersrpt.pdf