Out of pocket (California)

[lacompfun]

Applicant self procures wrist surgery. Pays out of pocket $7,500

Next files a comp case wrist injury 6 months later. Accepted.

Question

1. How does defendant legally process the bill?

Does it go through retro UR ? EOR?

[LawAdvocate]

You reimburse the Applicant directly for their cost. No UR or EOR. Self-procured care when claim is denied is directly reimbursable.

[lacompfun]

Seems there should be some type of financial limit due to reasonableness.

IE Applicant says gets a basic surgery which should cost $ 10,000 yet submits out of pocket bill at $ 150,000...

[LawAdvocate]

It goes to the risk you take when you deny a claim. You are risking not being able to control the medical costs/applying fee schedules when and if a claim becomes compensable. The Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd. case, where the Applicant self-procured an in-patient, out of state weight loss program at Duke University was all about the Benjamins, but the claims administrator did not act proactively to offer care. Therefore they waived any right to complain about price and had to reimburse the Applicant for his housing, travel, TTD incidentals and the full cost of the program. Cost was argued, but cost was not the deciding factor.

Claims that are denied typically cost over $25K more than claims that are admitted and adjusted for good cause, you are ceding control to the Applicant.

[steve appell]

Out of pocket bill for $150k? I do believe that.
$150k paid out of pocket? No way!
Get proof of payment before reimbursing a dime.

LATE

[jpod]

I don't think the original post said the claim was denied then the applicant self procured medical treatment; it said employee self procured treatment first, then six months later filed a claim that was accepted.

[LawAdvocate]

First there is no bill for $150K, that was a hypothetical. The bill is $7,500 and the defense billables to start that fight and then getting claims in a defensive position, because they fight everything anyway is an exercise in counter productive claims handling.

It was not denied, it was just filed post-fact, I still don't see $7,500 for a wrist surgery to be that out of the box. It is a little high, but not that high, and it really depends on which procedure was completed. I have paid over $15K fee schedule for a wrist surgery as a claims examiner.

[vampireinthenight]

I would retro UR it and have it reviewed for fee schedule rates. Assuming it is actually shown to be necessary for the claim you now have on file. Medical incurred prior to filing of a claim form is always a tough issue.

[lacompfun]

Correct.. it was a hypo say if it was $ 150,000 out of pocket.... sorry since unclear.... amount of out of pocket was $,7500 about in real case.

An EOR or bill review might be helpful. The bills do lack foundation as somewhat unclear.

It started with self procured surgery.... then later he filed the claim which is accepted.