Do it Right or Pay the Price (of Medical Bills)
When an injured worker receives a medically necessary treatment, the employer or insurance carrier is responsible for payment of the treatment when the claim has been accepted or established. See NYCRR section 325-1.25. However, when the treatment is not medically necessary or under the Medical Treatment Guidelines, the carrier can object by filing the New York State Workers’ Compensation Board C-8.1 form (a copy should go to the WCB, the employee, their representative and the health provider). Unfortunately, if the objection is late or improperly completed the carrier would be found liable for the unnecessary medical cost.
Within 45 days after the carrier receives the bill, the carrier shall pay the bill or notify the provider and the board using the C-8.1B form that the bill is not going to be paid and provide the basis for nonpayment. Alternatively, if the carrier has not objected within 45 days, the carrier is liable for payment of the full amount billed up to the maximum amount according to the fee schedule. A legal objection to a medical bill is filed on a C-8.1B, as opposed to a valuation objection which is filed on C-8.4.
While some of the following sounds simple or seems like common sense, failure to be accurate runs the risk of paying a bill that you would not otherwise be responsible for. The first step to properly completing the C-8.1 is checking the type of case that it is at the top, and completing the numbered sections 1-9. Under Part B, it must be checked where the treatment was performed (in New York State or out of New York State, and if it is dental treatment). The date of the bill must be included and the WCB document ID number – if the bill is not in the board file it must be attached with the C-8.1. The date of treatment, the amount of the bill and the amount in dispute must be filled in (sometimes only a portion of the bill is being disputed). See Matter of Voith Hydro, 2016 NY Wrk Comp G0734909 (the board affirmed C-8.1Bs found for the providers as the carrier failed to state the date of treatment, amount of the bill, amount in dispute, and attach the bill to the C-8.1B).
Moving to the legal objection checklist, at least one must be checked. As best practice, when the claim has been controverted the denial date must be filled in and if applicable, check another box. The reason for this is practice is to avoid liability if the claim is established but the bill still has legal issues, such as the medical report was not timely filed or legally defective, or the treatment provided was not causally related to the newly established injury site.
The other section for objecting to a bill on a legal basis is compliance with the Medical Treatment Guidelines. Of course, this section only applies if the injury/condition is covered by the Medical Treatment Guidelines. It is best to include the MTG reference and a brief explanation. The more information provided the better the odds of having the dispute found in favor or the carrier.
If the legal objection is resolved for the provider the carrier has 30 days to pay or raise valuation objections. By ensuring the C-8.1B is properly and completely filled out the chances of success at the hearing level increase and there is no risk that a ruling finding the bills for the provider based on a defective C-8.1B. If a question arises, do not hesitate to reach out to defense counsel to clarify the best way to complete the C-8.1B.