Approval of Multiple Office Visits Under the Medical Treatment Guidelines
By: Michael Parker
The Medical Treatment Guidelines have a provision where once a doctor obtains approval for routine maintenance visits, sometimes referred to as continuity of care, the doctor does not have to submit a new 1010 for each subsequent office visit. The rule is designed to allow a doctor to see the patient up to 12 times in the first year after the accident for routine office visits without a new 1010 each time. After that first year where up to 12 office visits are approved by the original 1010 approval, the doctor must submit a new 1010, which if approved, is good for up to 4 more office visits. See 40 La.Adim.Code Pt. 1, 2715.
NOTE – this rule only applies for routine office visits and does not apply to requests for additional treatment such as MRIs or injections.
But what happens if during the approval period something changes, and the claim is denied? For example, you determine that the claimant has committed fraud, or you determine that a particular body part should not be covered as a result of the work accident. Can the doctor continue to rely upon the original 1010 approval to treat the claimant and are you responsible for payment of the billing associated with that treatment? Even though you have filed a 1002 – notice of controversion or suspension if you do not notify the doctor that no further treatment is authorized, the doctor can rely upon the approval and submit billing to you for payment.
There is no doubt that when you get such a bill after a claim has been denied or settled that you will be reaching for the aspirin and trying to figure out a way not to pay the bill. The best protection for you in this situation is to notify every healthcare provider who is treating the claimant that no further treatment will be authorized when you file the 1002 controversion or when the claim is settled. It is recommended that this notice be sent by fax or email so that it can be documented in your file. If you simply call the doctor’s office and tell them no further treatment will be authorized the message may be lost and it is your word against a staff person who may no longer be working at the doctor’s office that all prior authorizations were revoked.
As always, documentation is the key in a situation like this. Don’t get caught having to pay a bill on a denied claim because you didn’t let the health care providers know that all prior authorizations have been rescinded.
