Effective July 1, 2017, the Georgia State Board of Workers’ Compensation has amended Board Rule 205 regarding authorization of medical treatment. The Board also issued a new form called a “WC-PMT.” Claimants’ attorneys will file the WC-PMT to have the Board schedule a conference call within five business days with the adjuster, the ALJ, and the claimant’s attorney regarding the authorization of the requested medical treatment. Claims handlers must now be prepared to handle conference calls regarding medical treatment or will have to refer the case to counsel, at least for the handling of the conference call. A copy of the WC 205, WC-PMT form, with new changes, is attached to this paper.
Years ago, the Board issued the WC-205 form. According to Board Rule 205, when a medical provider sends a WC-205 to an adjuster requesting authorization for a referral or medical treatment, the adjuster has five business days to controvert or authorize the treatment. If the adjuster did not answer, the treatment was deemed automatically authorized. Many medical providers do not know to use this form. Even where they did, the providers would not furnish the treatment without explicit approval from the insurer.
The ALJs at the Board have become increasingly frustrated with employer-insurers who do not timely approve routine medical referrals and visits. For the most part, the ALJs have limited the use of the WC-205 to situations where the authorized physician is requesting treatment for an accepted condition. According to the ALJs, many adjusters simply ignore the WC 205s, do not respond to them, and fail to provide timely approval of routine medical visits.
The revised version of Board Rule 205 is intended to address this issue. The rule now allows “an authorized medical provider” to complete a WC 205 and seek advance authorization of treatment. The employer insurer must respond within five business days. Additionally, if the employer insurer denies the treatment or testing within the first five business days, they must also controvert the condition within 21 days of the initial request (16 days after the initial five-day deadline).
Let me repeat this point: when a WC 205 is received, approval or denial for the treatment of testing must be given within five days. If the treatment or testing is denied, there is an additional mandatory step of filing a WC 3 within 21 days from the receipt of the initial request. Denying a medical procedure is a two part process when a WC-205 is received from a medical provider.
Note that the revised Rule 205 allows employer-insurers to change their mind within the16-day period after the initial five day response requirement. In a situation where an adjustor cannot decide within five days whether to approve the request, the request should be denied. The adjustor then has another 16 days to gather the necessary information and make a final decision. If the adjustor has written a doctor, but the doctor has not responded within the 21 days, the better course may be to deny the treatment or test. In that situation, the claimant and/or claimant’s attorney should be notified that a decision cannot be made until the doctor responds to the written request.
If no response is received from the employer insurer within the initial five day denial, the claimant’s attorney can file the WC-PMT form to schedule a telephonic conference “not more than five business days from the date of the petition.” The five business day deadline begins to run as soon as the WC-PMT is filed with the State Board and copied to the employer-insurer. Rule 205 notes that “postponements [of the telephonic conferences] will be discouraged and granted only for good cause shown.” Parties requesting a postponement of the telephonic conference must agree to a rescheduled conference within five business days of the original conference date.
The five business day deadline may well create problems where someone is out of the office and is not necessarily even aware of the telephonic conference or medical request yet.
Whenever an adjuster is out of the office, it will be essential to have “an out-of-office” notification along with information regarding whom to contact when immediate assistance is needed.
Claimants’ attorneys will likely be eager to file a WC-PMT every time a WC-205 is ignored. Hopefully, the medical providers will not flood your office with these requests. This Rule is intended to authorize routine medical procedures and testing which should not be delayed. Beware of claimants’ attorneys who may encourage providers to seek authorization for new problems such as psychiatric treatment in addition to whatever physical injuries a claimant has. Adjusters who do not respond to a WC-205 in that situation may be faced with a telephonic conference regarding authorization of a medical condition that may or may not even be compensable. Do not hesitate to confer with counsel in that circumstance or to deny unrelated treatment or testing entirely by filing a WC 3 to controvert.
No Board form is considered filed unless a copy of the actual form is sent to you by the opposing party or opposing counsel. Notification of a form filing from the Board is not enough to constitute proper service. In other words, any claimant’s attorney who files a WC-PMT form must send a copy of that form to you immediately after filing it with the Board. WC-PMT forms must also be flagged and docketed to ensure that you are adequately prepared for the telephonic conference call.
This new system is designed to ensure timely authorization of the normal and appropriate course of treatment. Do not read this Rule as limiting your right to deny medical treatment or referrals in appropriate circumstances. It is essential that all WC-205s received in your office are timely flagged and docketed to ensure that any responses are filed within five days and to further ensure that appropriate follow-up is made within 21 days by either specifically authorizing treatment or filing a WC 3.
Be prepared but not intimidated. When an adjuster is on a conference call, the ALJ will likely be frustrated if the ALJ feels that routine and customary treatment has been unreasonably delayed or that the file is being ignored. The ALJ should not take issue with an adjuster who has been “paying attention.” If the issue is complex rather than routine, the ALJ should encourage the claimant’s attorney to request a full evidentiary hearing.
I will be happy to provide further information and updates on this or any other workers’ compensation topics. Should you have any questions about the new WC-PMT forms and WC 205s, please feel free to contact me at firstname.lastname@example.org or (770) 557-3362.