Opinion ID: 2279846
Heading Depth: 1
Heading Rank: 1

Heading: krs 342.020 and the applicable regulations.

Text: KRS 342.020(1) entitles an injured worker to reasonable and necessary medical treatment for a work-related injury and requires a medical provider to submit a statement for services within 45 days after initiating treatment as well as every 45 days thereafter. The statute requires the worker's employer to pay the provider directly within 30 days of receiving a statement for services but directs the commissioner (formerly the executive director) to establish conditions for tolling the 30-day period. Finally, it authorizes the commissioner to adopt administrative regulations establishing the form and content of a statement for services as well as procedures for resolving disputes over the necessity, effectiveness, frequency, and cost of medical services. Although KRS 342.010(1) gives an injured worker great latitude in selecting a treating physician and course of treatment, the worker's freedom is not unfettered. KRS 342.020(3) and (4) permit employers to provide medical services through managed care systems, subject to specified requirements among which are an informal method of resolving disputes concerning the rendition of services [4] and a provision for obtaining a second opinion at the employer's expense. [5] Another requirement is a provision for utilization review to assure among other things that the course of treatment is reasonably necessary, appropriate, and cost-effective. [6] KRS 342.020(7) (formerly KRS 342.020(3)) states clearly that employers are not required to pay for medical treatment that fails to provide reasonable benefit to the worker. [7] The courts have construed KRS 342.020(1) as placing on an injured worker's employer the burden to contest a post-award medical bill within 30 days or to pay it. [8] At issue presently is whether a final utilization review decision refusing to pre-authorize medical treatment is equivalent to a statement for services to which the 30-day requirement pertains. 803 KAR 25:096, § 8(1) requires a medical payment obligor to tender payment or file a medical dispute and motion to reopen within 30 days of receiving a completed statement for services. 803 KAR 25:096, § 1(5) defines a statement for services as follows: (a) For a non-pharmaceutical bill, a completed Form HCFA 1500, or for a hospital, a completed Form UB-92, with an attached copy of legible treatment notes, hospital admission and discharge summary, or other supporting documentation for the billed medical treatment, procedure, or hospitalization; and (b) For a pharmaceutical bill, a bill containing the identity of the prescribed medication, the number of units prescribed, the date of the prescription, and the name of the prescribing physician. Pre-authorization is a process by which a carrier assures a provider that it will pay the bill for a proposed medical service or course of treatment. [9] The regulations require a provider's pre-authorization request to be submitted to another medical expert for utilization review, [10] i.e., a review of the medical necessity and appropriateness of medical care and services for purposes of recommending payments for a compensable injury or disease. [11] Whether conducted before or after the treatment is provided, [12] the purpose of utilization review is to provide the parties with an independent medical opinion concerning the compensability of medical treatment in order to help them resolve disputes without resorting to litigation. [13] Initiation of the process tolls the 30-day period for challenging or paying medical expenses until the date of the final utilization review decision. [14] KRS 342.325 vests ALJs with jurisdiction over all questions arising under Chapter 342, including medical disputes. 803 KAR 25:012 sets forth the procedure for resolving such disputes. It provides that an employee, employer, carrier or medical provider [15] may file a Form 112 to contest the reasonableness and necessity of a medical expense, treatment, procedure, statement, or service which has been rendered or will be rendered. [16] In cases involving a post-award medical dispute, the regulation requires a motion to reopen and medical dispute to be filed within 30 days of receipt of a complete statement for services unless utilization review has been initiated. [17] If a contested expense is subject to utilization review, such as in the case of a pre-authorization request, the regulation prohibits a medical dispute from being filed before the process is exhausted [18] but gives the [t]he employer or its medical payment obligor 30 days after the final utilization review decision in which to file a medical dispute. [19]