Provider Certification in Delaware: And if they're not? The IAB Speaks . . .

In what appears to be the first ruling on this issue, the Delaware IAB has addressed the issue of what remedy is available to the parties when an injured worker seeks to treat with a medical provider who is not certified under the new medical statute, 19 Del. Code Section 2322D, Bertha Polk v. Green Acres Pavilion, IAB Hrg. # 1253843 (12/4/09) (Order). By statutory amendment of 1/17/07, Delaware law now requires that treatment with a non-certified provider be pre-authorized by the insurance carrier in order for such treatment to carry the presumption that it is reasonable and necessary.

 So what happens if the carrier refuses to pre-authorize such treatment and the claimant participates in care with the non-certified doctor?  Do the services remain ineligible for payment, as the carrier argued in this case?  If not, what bite does the new statute impose in terms of scrutinizing medical care for compliance with the Practice Guidelines or adherence to the esoteric concept of reasonable and necessary?

In the instant case, a Delaware claimant relocated to North Carolina.  She argued that there were no Delaware-certified providers in that state nor was there any inducement for a North Carolina provider to become certified; to hold that she was ineligible for her medical bills to be covered under workers compensation under these circumstances would be a harsh and inaccurate interpretation of the statute.

The Board took a careful look at 19 Del. Code Section 2322D(a)(1) and concluded that the following framework applies for this statute:

(1) Where out-of-state medical providers are concerned, the State can only force adherence to the Workers Compensation Health Care System if the provider chooses to become certified within the system;

(2)  If the provider is certified, whether in-state or out-of-state, the appropriate remedy for denial of bills if the treatment falls within one of the six (6) Practice Guidelines is a referral to Utilization Review (UR);

(3) If the treatment at issue does not fall within a Practice Guideline or the provider in question is not certified, the carrier would follow the prior practice of denying payment and the claimant must file a DACD Petition ("Additional Compensation Due") and that remedy would apply in the instant case.

The Board re-iterated that the statute does not state that services rendered by a non-certified provider are ineligible for payment, but rather, they will not be presumed reasonable.  The claimant carries the burden of proof on a showing of reasonable and necessary.  The employer's Motion to Dismiss the claimant's DACD Petition in this case was therefore denied.

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