Medical Benefits


I’ve written before about the E/C’s jurisdictional defense to a claim for unpaid bills from authorized providers.  The Claimant has no standing to sue for payment of the bills and the Judge has no jurisdiction to order the payment of the bills.

Only the Agency for Health Care Administration (AHCA) has jurisdiction to settle such disputes.   In fact, sections 440.13(11)(c) and 440.13(3)(g) state that the Claimant does not have responsibility for such bills.   In the past, I’ve written the following on the matter:

Section 440.13(11)(c) dictates that the Agency for Health Care Administration (“AHCA”) has “exclusive jurisdiction” to decide any matters regarding provider reimbursement.  As long as the Carrier authorizes care with the doctor, the dispute about the doctor’s bills is outside the jurisdiction of the Judges of Compensation Claims.”

However, it is important that when the E/C asserts this defense, it is “buying” the bills and the treatment connected with said bills. (more…)

In a state with the second highest incidence of drug overdose deaths in the nation, I am surprised that this type of legislation is getting steam. 

I’ve written before about physicians prescribing drugs and dispensing themselves.  Chapter 440 has specific language that forbids an E/C from choosing a pharmacy for Claimant.  Per s. 440.13(3)(j), a Claimant “shall be entitled, at all times, to free, full, and absolute choice in the selection of the pharmacy or a pharmacist dispensing and filling prescriptions for medicines under [Chapter 440].” 

Some doctors were taking advantage of this provision by dispensing the drugs themselves and charging E/C’s exorbitant amounts for said drugs.  A trial court ruling seemed to hamper into such schemes (See Bonanno v. Diocese of Venice Epiphany Cathedral Catholic Church.)

Now there is pending legislation that would make it legal for doctors to control the dispensing of drugs. 

Bad idea.

(more…)

(Ed. note: I worked on an a separate appeal on this case, albeit with a different date of accident and a different Carrier.)

The number of Carriers contracted into a manage care plan has dwindled over the years.  However, there are still some left and if you are a claims professional or Employer still associated with such a managed care plan, it is important to understand all of the legal “wrinkles” in your plan. 

For one, section 440.134 works hand-in-glove with s. 440.13 and with this most recent case it is important to understand there can be two opportunities for a Claimant to choose a change in doctors.  (more…)

(Consider this post as my scary Halloween article for E/C’s.)

This issue is hotly debated now among Carriers.  What do you do when an authorized doctor requires Claimant’s non-compensable condition be treated before the doctor will treat the compensable injury?   For example, the authorized W/C surgeon will not perform surgery on the compensable back injury until a doctor clears Claimant’s cardiac condition. 

Does the E/C have to authorize cardiac care for a non-compensable condition just so the doctor can treat a compensable lumbar condition? 

The unfortunate answer is “yes.” (more…)

Sorry for the absence, loyal readers.  The holiday season, more appellate work, and the entrance of my first child into the world kept me away.  But, I am back with a brand new First DCA case summary.  Once again, we return to a medical vendor dispute and whether a Claimant even has the right to file a Petition for unpaid authorized medical bills. 

I think we know where this is going. . . (more…)

For a Comp nerd like me, the First DCA oral arguments is my second favorite part of the Convention, right behind Case Law Update.  For many practitioners, adjuster, and employers oral arguments are the best opportunity to see how chapter 440 is interpreted and shaped.

Tallahassee is a far drive for many of us, so whenever the First DCA goes on the road and opens their docket at the Convention, it is a delight.  As is every year, the Convention hosted two cases heard in front of two panels of judges.  I want to focus on the first one, McGraw v. Sauer, Inc., 1D10-791, and what effect it may have on an E/C’s right to seek an IME. (more…)

When the 2003 changes came into effect, many people looked at the fee provision as the biggest change.  But, in terms of everyday practice in Workers’ Compensation, the change to the IME provision had a profound effect.

Section 440.13(5)(a), was thought to limit each party to just one IME:

“In any dispute concerning overutilization, medical benefits, compensability, or disability under this chapter, the carrier or the employee may select an independent medical examiner.  The employer and employee shall be entitled to only one independent medical examination per accident and not one independent medical examination per medical specialty.”

While the intent of Legislature is clear–one IME per specialty only–the intent of whether a party could have just one IME examination per claim was left in doubt.  Many judges allowed “updated” IME’s upon motion of a party, if it was with the same doctor, especially when it had been years since the last IME.  However, the new(er) language of 440.15 is clear: “entitled to one independent examination per accident”. 

Therefore, many judges would deny updated IME’s for this very reason.  Until now. . . (more…)

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