Medical Fee Dispute and the Adjuster's Duty to Pay Undisputed Charges
A Wasilla worker with an accepted back claim treats at a clinic. The carrier receives a $4,800 bill for a series of physical therapy sessions and a $1,200 bill for an independent medical examination requested by the carrier. The adjuster believes the physical therapy charges exceed the community rate and that some sessions were not medically necessary. The clinic has not provided the therapy notes despite two requests. The IME bill is from a physician the carrier selected. The worker's treating physician supports the therapy as necessary. The adjuster is also reviewing a $600 charge for a brace the worker bought without prior authorization.
1. Analyze how the adjuster should handle the $4,800 physical therapy bill, including the effect of the missing notes.
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The carrier must pay charges that are medically necessary and within the applicable fee schedule or community rate. A dispute about excess charges or necessity does not justify ignoring the bill; the adjuster should:
- Pay the undisputed portion promptly and dispute only the specific charges that are genuinely at issue, with a written explanation.
- Continue to request the therapy notes; if the provider fails to supply documentation needed to evaluate necessity, the carrier may dispute those specific sessions, but it should document the requests and the provider's nonresponse.
- Compare the charges to the fee schedule or community rate and identify the specific line items that exceed it.
- Consider the treating physician's support for the therapy as evidence of medical necessity, which weighs against a blanket denial.
A blanket refusal to pay the entire bill because notes are missing is risky; the carrier should pay what is supported and dispute the rest with specificity, preserving the worker from balance billing for covered charges.
2. Who is responsible for the $1,200 IME bill, and why?
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The carrier is responsible for the IME bill because the carrier requested the examination. An IME obtained by the carrier to evaluate the claim is a cost of the carrier's investigation, not a treatment charge to be passed to the worker or disputed as if it were the worker's medical care. The adjuster should pay the IME bill as a claim-handling expense and should not offset it against the worker's benefits. If the carrier later disputes the IME's conclusions, that does not change who pays for the examination.
3. How should the adjuster treat the $600 brace the worker purchased without prior authorization?
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Lack of prior authorization does not automatically make a medically necessary brace noncompensable, but the adjuster should evaluate whether the brace was reasonable and necessary for the accepted condition. The adjuster should:
- Obtain the prescription or the treating physician's statement supporting the brace.
- Confirm the brace is related to the accepted back condition and not an unrelated purchase.
- Check whether the cost is within the fee schedule or community rate.
- If supported, pay it; if not, dispute it with a specific written reason and give the worker notice of the dispute.
The adjuster should not deny solely for lack of pre-authorization if the treating physician supports the device, because the carrier's obligation is to pay reasonable and necessary medical care for the accepted condition.