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What happens if workers’ comp carrier doesn’t respond to referral request?

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in Leaders & Managers,Management Training

BY RALPH A. PETERSON and JOHN F. WINDHAM

Q. The authorized treating physician of an employee who suffered a job-related injury referred the employee to a pain management specialist. Now our employee tells us that our workers’ compensation carrier has not responded to the referral request. The carrier evidently believes that this referral is not reasonably and medically necessary. Can it deny the referral request for that reason?

A.
Under a recent Florida appellate court decision, this is a “gotcha” situation that employers and carriers can avoid.

The court has ruled that, under pertinent provisions of the Florida Workers’ Compensation Law, a carrier that fails to comply with the statutory requirement for responding to referral requests forfeits the right to contest whether the referral is reasonably and medically necessary.

The statute has a relatively short response period—either three or 10 days depending on what type of referral is being requested. If the carrier (or the employer) fails to respond within those deadlines, it is assumed to have consented to the medical necessity of the referral and that the referral and specialist consultations are valid and reimbursable.

Advice: Always respond to a physician’s request for referral to another medical specialty, even if the response is to deny the request. Failing to respond will mean giving up the right to contest the referral’s medical necessity.

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