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Court: Prior-Approval Rule Does not Require Payment for Claims Unrelated to Workers' Comp

October 6, 2011
Related Topics: Workers' Compensation, Medical Benefits Law, Unemployment Compensation, Compensation Design and Communication, Compensation, Legal, Latest News
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Georgia's Supreme Court upheld a state rule this week giving insurers and self-insured employers five days to respond on whether they will pay for workers' compensation-related medical claims in the state. However, the court said the rule only applies to compensable injuries.

Georgia's State Board of Workers' Compensation says insurers and self-insurers must notify medical providers of whether they will pay for a procedure within five days of receiving a pre-approval request. If the deadline is missed, payment is considered to be approved automatically by the insurer.

In a decision issued Oct. 3, the Supreme Court said the rule can't be used to make insurers pay for claims unrelated to workers' comp cases.

"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 decision reads.

The case, Mulligan vs. Selective HR Solutions Inc., centered on a woman who underwent two back surgeries for injuries sustained in 2005 and 2007. While she sustained the first back injury at work, the second surgery may have resulted from an accident in her home, according to court records.

Selective paid for Maria Mulligan's first surgery under a workers comp claim, but argued it shouldn't have to pay for the second surgery without a second opinion. The court's decision says Selective took more than a month to respond to a surgery pre-authorization request submitted by Mulligan's doctor.

Georgia's appeals court ruled that Selective was not required to pay for Mulligan's second surgery, arguing the state workers comp board put an unfair burden on insurers to prove whether an injury is compensable.

The state Supreme Court upheld the appeals court ruling, but it disagreed with the reasoning, saying the rule only applies to injuries already deemed to be workers' comp-related.

Sheena Harrison writes for Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.

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