Georgia's State Board of Workers' Compensation recently ruled that insurers and self-insurers must let medical providers know whether they will pay for a procedure within five days of getting a pre-approval request. Should the deadline be missed, payment is considered automatically approved by the insurer.
Georgia’s Supreme Court recently upheld the state rule, but said it is only applicable to compensable injuries. In the October 3 ruling, the state’s Supreme Court said the rule cannot be used to make insurers pay for claims that are not related to workers’ comp cases. The decision reads, “The fact that an insurer or self-insurer does not timely respond to a request for treatment or tests, and thereby, becomes obligated for pre-approval of that which is requested does not abrogate the threshold mandate that the medical care be for a compensable injury.”
The case, MULLIGAN VS. SELECTIVE HR SOLUTIONS INC., involved a woman (Maria Mulligan) who had two back surgeries for injuries she received in 2005 and 2007. Court records show though while she did get her first back injury at work, the second surgery could have been the result of an accident she sustained in her home. Her employer paid for Mulligan’s first surgery under a workers’ comp claim, but did not want to pay for the second surgery without getting a second opinion. The court’s decision said the company took more than a month to respond to a surgery pre-authorization request that was submitted by Mulligan’s doctor.
The appeals court decided the company would not have to pay for her second surgery—saying the state workers’ comp board had put an unfair burden on insurers to prove whether or not an injury is compensable. The state Supreme Court upheld the appeals court ruling—but did not agree with the reasoning. The state Supreme Court said the rule is only applicable to injuries that are already deemed related to workers’ comp.
Modern Business Associates is an HR company that focuses on payroll and HR outsourcing. We routinely work with clients on workers’ compensation cases. As a Professional Payroll and HR outsource organization, our clients rely on us to help them effectively deal with these kinds of topics.
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