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Workers' Compensation Blog

Can I Choose My Own Pharmacy?

Thursday, February 14, 2019

If I can choose my own doctor can I choose my own pharmacy?

Several times a week we receive calls from clients that they are at their local pharmacy and their prescription was denied. This can often be the pharmacy that will not call the insurance adjuster, the insurance adjuster that does not respond or confusion over the mandatory waiting period to fill narcotic prescriptions. The result is frustration by all parties involved and an onslaught of misinformation ultimately resulting in the delay of much needed prescriptions.

What can I do to avoid this?

To alleviate this stress often clients will choose to use a mail order pharmacy. The mail order pharmacy usually takes the guess work out of why a prescription is denied. The mail order pharmacy is more likely to trouble shoot, call the adjuster directly and even reach out to doctors when a letter of medical necessity is required. Your local pharmacy may be too busy or overwhelmed to make all of these calls on your behalf. The downside is when you are filling opioids or narcotics such as oxycodone or oxycotin there are additional steps that may need to be taken.

With the many restrictions recently put in place to prevent opioid overdoses it may take an extra step or two depending on what medication you are taking. One of these restrictions is the requirement that the physical prescription must be sent to the pharmacy. These restricted medications are not permitted to be e-filed except in limited circumstances or with specific certifications. However, most mail order pharmacies have made it as easy as possible to alleviate the burden on the client. For example, they will provide UPS overnight envelopes to the doctor to overnight the prescription. Also, they recommend you see your doctor a few days before your refill is due and the doctor can post date the prescription, that way by the time the pharmacy receives the prescription it is on the day when the medication can be filled and the pharmacy will overnight the medication with no cost to you.

Can I choose my own pharmacy?

Over the past several years there have been frequent news worthy items regarding pharmaceutical contracts between insurance companies and pharmacies. These contracts allow a specific insurer to provide medications to the insured for less money if the specific pharmacy is used. Often the discount can be as great as 30% less the average wholesale price of the medication. Since the pharmacy is dealing on a very large scale they are able to provide this discount. Depending on the Insurance Company they will allow you to choose your pharmacy, but they will only pay out at the negotiated rate, very similar to doctor's taking the Maryland Workers' Compensation Rate.

While this issue is still being decided in the courts most insurance companies will payout at the charged rate by the pharmacy. It is best to find a mail order pharmacy that serves the Workers' Compensation community exclusively. Often they will forgive the amounts that the insurance company refuses to pay or that the commission will not award and always be aware that the pharmacy is not charging any additional filling fees.

Why is it taking so long for my medical bills to be paid?

Wednesday, October 10, 2018

HCFA Forms

Maryland Workers’ Compensation laws require that medical bills be submitted on HCFA forms. These are standard billing forms used by most insurance companies that have fields for the appropriate and necessary CPT (current procedures terminology) codes. However, some practitioners may not be aware that this is a requirement for workers’ compensation claims or that the bill may be denied if it is not submitted properly on the HCFA form. The adherence to this rule varies between insurance companies, however if your provider is having trouble getting bills paid then the first step should be to ensure that the bills are submitted on HCFA forms. As an easy reference the workers’ compensation website provides a blank downloadable HCFA form.

Itemized Billing

Another reason your workers’ compensation medical bills are not getting paid could be that the bill that was sent to the insurance company was not itemized with the proper CPT codes. The workers’ compensation carrier cannot pay bills that are not properly itemized with these specific codes, similar to the codes that a primary care physician would provide to a private insurance company. In addition, many carriers also require that each office visit note from the billed dates of service are provided with the bill. This requirement is to ensure that the visit was related to a compensable body part or condition. Where the system fails is when the carrier denies payment of the medical bills and does not site to the reason it is denied. Often it is a clear case of one department not providing the proper medical records to the carrier’s billing department. Instead of working together the billing department denies the payment of the bill. To resolve this confusion and to save time our firm often will attach the appropriate medical report when sending in any reimbursement or bill pay request even though the carrier may have previously received the report.

Collections Letters

When a medical bill has not been paid, for various reasons, the provider will often send the bill to a collections agency or will seek payment from the claimant. It is important to know that a provider has their own course of action within the workers’ compensation commission to collect on bills for approved medical treatment. This is done through submitting a C51 claim for medical services to the commission. The commission will then issue an order nisi to the carrier requiring payment of the bills. The provider can request penalties, fees and interest if the bill is unpaid for over 45 days and the carrier failed to provide written communication of the denial. In addition, a claimant may notify the collections agency or doctor’s office that under Sec. 9-660, Labor and Employment Article, MD. Ann. Code, medical expenses related to an accepted and related workers’ compensation claim should be directed to the workers’ compensation insurance carrier.

Contact your Attorney

Facilitating payment of medical bills is one of the services we provide to our current and past clients for workers’ compensation cases we have handled. If you have not filed a claim for medical services that you feel are related to a workers’ compensation claim please contact our office as soon as possible so that we may assist you before these bills effect your credit.

The “Going and Coming Rule” in the District of Columbia

Thursday, September 13, 2018

What tends to surprise a lot of our clients is the fact that, in the District of Columbia, injuries sustained by employees while traveling to work or traveling home from work, are not covered by the District of Columbia workers’ compensation statute. The DC workers’ comp statute is codified in Title 32 of the DC Code. In order for an injury to fall within the statute, the injury must “arise out of” the injured worker’s employment.

An injury is said to ‘arise out of’ ones employment if the injury would not have occurred ‘but for’ the fact that an obligation of the employment duties puts the injured worker in a position where he gets injured. An injury is therefore, said to ‘arise out of’ ones employment when it occurs in the course of the employment on account of conditions of the employment which are the immediate cause of the injury.

Therefore, while we must travel via some mode of transportation in order to be able to arrive at our place of employment, or to return home, the traveling itself is not a condition of the actual employment, and is not an obligation of the physical work we do; the traveling and the work are separate and apart from one another.

However, there are instances where an employee’s travel to and from work can be considered to be a part of the employee’s actual work and an obligation of the employee’s employment.When this occurs, injuries sustained by the employee while traveling to and from work would be an exception to the ‘going and coming rule.’ Some factors that the court will consider are the following:

  1. Was the employee paid for his time to travel to and from work?
  2. Was the employee driving a company vehicle to and from work that he parks in his “home garage?” 
  3. Is the employee paid gas money to get to and from work? 

While there is no bright-line rule, the court will consider one or more of the above factors to see if there exists an exception to the “going and coming rule,” allowing the injury sustained while traveling to or from work to fall within the DC workers’ compensation statute.If any additional information is needed, I can be reached by email: lpisano@bsgfdlaw.com, or on my direct work number of: 301-740-3304.

Advice for the Apprehensive Injured Worker

Wednesday, September 05, 2018

A few times a week I get a call from an injured worker who is considering filing a workers’ compensation claim but is concerned about the repercussions that may take place after filing.

While it is understandable, and in certain circumstances a very real concern that an employer may retaliate against an injured worker after a claim is filed, if you are injured on the job it is important to understand what rights you may be giving up if you let your concerns influence you to not file a workers’ compensation claim. You may be giving up more by deciding not to file a claim than you would even in the worst case scenario for employer retaliation: termination. (Maryland is an “at-will” employment state, meaning an employer can fire an employee for any non-illegal reason. However it is against Maryland law to fire an employee for filing a workers’ compensation claim).

By failing to file a claim you may be giving up compensation at 2/3s of your pre-taxed wages for the period of time you are unable to work while you recover from your work injury. For municipal workers, this benefit can often be paid at 100% of your wages. Often times this means exhausting your hard earned personal, vacation and/or sick leave when your employer or its insurer is the legally responsible for paying your wages for each day missed. This benefit becomes especially important if you are separated from your employment. Whether you are separated from employment or not, you are still entitled to compensation if you cannot do your job and your doctor agrees that you must be out of work.

Perhaps most importantly, Maryland law requires the Employer/Insurer to pay for all of medical treatment necessitated by your work injury. Maryland is unique in that you have the right to seek treatment with a doctor of your choice. And most important of all, there is no time limitation on your ability to seek treatment as a result of a work injury. (The right to fight for treatment never expires once a claim has been timely filed and accepted, however, there are no guarantees your employer or their insurer will authorize the treatment you wish to have – a good reason to consult with a legal professional). If you fail to timely file a claim with the Workers’ Compensation Commission, often times the insurance adjuster will take longer to authorize treatment or refuse to authorize your care altogether as there is no real motivation to do so. By successfully filing a claim, you’re guaranteeing at least the right to fight for your employer to pay for your lifetime medical care.

Compensation for permanent disability is the last main benefit available to those who are successful in filing a workers’ compensation claim. Often times the money received for an individual’s permanent disability does not truly compensate him/her for the affect their injury has had on their life - especially with more serious injuries. However, some compensation is certainly better than receiving no compensation at all. By failing to file a claim, you forgo this right altogether. Some other important benefits to filing a claim are medical mileage reimbursement, vocational rehabilitation and temporary partial disability – to name a few.

You work hard at your job every day, giving up precious time with your family to help further your companies’ goals. If you get hurt while on the job you owe it to yourself to protect both you and your family by filing a claim. You should not have to pay out of your own pocket for medical treatment, struggle to make your bills because you are incapable of earning wages, or worse yet be forced to suffer from a life altering disability without receiving any assistance to get you back on your feet.

So if you get hurt on the job – protect yourself and your family by filing your claim. And if you’re concerned about the potential repercussions of doing so, consult with legal counsel to make sure you understand not just what problems may arise if you do file your claim, but what problems may arise if you don’t.

Call attorney Charles Schultz, Esq. today at 410-769-5400.

Report First – ‘Tough It Out’ Later

Wednesday, April 25, 2018

The first thing you must do when you get injured on the job is to notify your supervisor immediately. You do not have to notify your employer in writing, but it makes your claim much easier if you do. Whichever way you choose to notify, make sure you indicate the date and the time of the accident, and every body part that was injured.

Notice should be given even for minor injuries. You don’t have to miss work to report an injury. You can choose to tough it out and keep working after you get hurt but you should document it whether or not you can continue to work.  After reporting it to your supervisor, the next way to document your injury is to go see a doctor to get checked out. Whether you see your primary doctor or go to a clinic you want to make sure someone evaluates your injury so that if your condition gets worse down the road, you have already created a paper trail that will support you getting the treatment you may need later.

You Must Go Beyond Your Internal Claim Number

Once you report the injury, your employer may request that you fill out an incident report and even give you their own internal claim number. However, remember that reporting the injury does not mean that you have done everything to protect yourself. You still have to file a claim with the Maryland Workers’ Compensation Commission to fully make sure you are protected.

Although it’s ideal to notify your employer of a work-place injury as soon as it happens, Maryland law states that an injured worker has ten (10) days to report the injury. The law even provides some exceptions if you report beyond the ten (10) day requirement, but late reporting can give your employer a basis to contest or dispute your claim even though you might have a valid workers’ compensation claim. Therefore, you should report your injury as soon as it happens.

Follow These Steps If You Are Injured On The Job

So if you are injured on the job (even if it’s a minor injury and you do not miss time from work) remember these three easy steps:

  1. Report immediately (preferably in writing);
  2. See a doctor (even your primary care provider); and
  3. Contact the lawyers at Berman, Sobin, Gross, Feldman & Darby to file your claim!

Jury Verdict In Favor Of Montgomery County Bus Driver

Tuesday, December 19, 2017

School bus drivers spend hours transporting children to and from school in order to ensure that they arrive in a safe and timely manner. After years of performing this vital service for the community, the wear and tear on the bodies of bus drivers can have a profound impact on their ability to do their jobs. Natalie Whittingham, Ken Berman, and their team at Berman, Sobin, Gross, Feldman & Darby, LLC secured workers’ compensation benefits for a decades long school bus driver who developed chronic pain in her tailbone after years of bouncing up and down in an uncomfortable bus driver’s seat. The Maryland Workers’ Compensation Commission had found that the Claimant, who required three surgeries as a result of her tailbone pain, suffered an occupational disease arising out of and in the course of her employment for Montgomery County. The Employer, in an attempt to overturn this Order appealed to the Circuit Court. After an in depth three day long trial before a jury, which included expert testimony by two doctors, medical records, and the testimony of lay witnesses as to the hazards of the Claimant’s employment, the jury came back in favor of the claimant, upholding the Workers’ Compensation Commission. Ken and Natalie were able to defeat the County’s appeal and preserve the rights of the injured worker.

The Law of Occupational Disease

The most commonly known work related injuries, or “accidental injuries” occur when an employee is injured in an accident on the job at a particular time and on a particular day. Some examples of accidental injuries include slips, falls and car accidents. However, some work related injuries occur only after many years of the worker repeatedly performing their job duties. The onset may be slow in nature and results from the conditions of the employment. These are known as “occupational diseases”. Examples of an occupational disease could include carpal tunnel syndrome, in this case coccydynia (like the Claimant here suffered), lung cancer and hypertension. Injured workers who suffer occupational diseases may be covered, even where there is some other disorder or condition which contributes to the occupational disease. Here, the Claimant developed the occupational disease of coccydynia after many years of bouncing around in uncomfortable bus driver seats around the same time that she experienced rapid weight loss. The jury found that where the occupation of bus driving was even only a partial cause of the disorder, the claim was covered under the Workers’ Compensation Act.

What To Do If You Think You’ve Suffered An Occupational Disease

The law of occupational diseases is a complex area of the Workers’ Compensation Act and requires an attorney with experience to navigate its intricacies. In order to pursue a claim for disablement caused by an occupational disease, a medical opinion, relating your employment to your disorder is required and a claim must be filed within a certain amount of time of receiving that medical opinion. If you believe that you’ve suffered an occupational disease from repeated exposure to the physical or chemical hazards of your employment, it is imperative that you contact an attorney right away. If you are injured at work, contact Ken Berman, Esq. at (301) 740-3300 or Natalie E. Whittingham, Esq. at (301) 670-6546.

Defending A Firefighter Who Was On Duty For 24 Hours And Injured

Tuesday, October 31, 2017

Fire Fighters work had to protect our communities.They are required to work long hours, sometimes – and in this Claimant’s case – 24-hour shifts, where they are on duty at all times, ready to respond to any emergency call that may come in.  Ken Berman, Nicole Lambdin, and Berman Sobin Gross Feldman and Darby protected the rights of a Fire Fighter who, while on a 24-hour shift injured his knee while stepping away from the fire station to pick up his dinner at the restaurant across the street.  At the time of the injury, the Claimant was on duty and required to stay close to the fire station so he could respond to an emergency call should one come in.  After the Claimant’s injury was found compensable at the Workers’ Compensation Commission, the Employer attempted to reverse the Order by appealing the decision., claiming that since he was going to get dinner, he was no longer “in the course of his employment”.  Ken and Nicole defeated the appeal and preserved the rights of the injured worker.

Protected Under The 'Coming and Going Rule'

While the Employer asserted that the Claimant’s injury was barred by the “coming and going rule,” a general principle that disallows compensation for injuries that happen when an employee is going to or from his/her place of business (although there are many, many exceptions to the “going and coming “rule and one should always check with an attorney to see if their injury is covered), the Circuit Court agreed that this injury did not fall into that category.  Instead, the Court agreed with the Claimant that his injury arose out of and in the course of his employment because the fire fighter, at the time of the injury was on duty, getting paid, and was required to respond to any emergency call that came in.  In fact, the Claimant’s supervisors allowed the fire fighters to leave the fire station to pick up food as long as they remained within a certain perimeter to the station – ensuring they could timely return in case of an emergency.  By demonstrating that the Claimant remained ready and capable to respond to an emergency and that his employers acquiesced to employees leaving the station but remaining with the perimeter, Ken and Nicole established that the Claimant was within his employment at the time of his injury.

Every Case Deserves Special Focus

This case is evidence of how complicated Workers’ Compensation claims can be.  While at first glance this claim could appear to not be compensable because the fire fighter was on a “dinner break”, a more detailed analysis proved that his injury is covered by the Act, and that the Claimant is entitled to both medical and financial benefits.  The attorneys at Berman Sobin Gross Feldman and Darby can help you obtain the benefits and medical coverage that you are entitled to.  If you are injured at work, contact Ken Berman, Esq. at (301) 740-3300 or Nicole Lambdin, Esq. at (410) 769-5400.

The Importance of Documenting All of Your Injuries

Tuesday, July 18, 2017

All too often when workers are injured the focus is on the most severe parts of the body hurt. Frequently the minor pains and bruises from other parts of the body are ignored. However, in a workers’ compensation claim it is very important to report every hurt, bruised, or swollen body part no matter how minor it may seem at the time. The human body is interconnected and when you fall, for instance, you may land on your knee, but your hands may have eased the impact, which can cause shoulder and arm pain as well. If you injure your back, the nerve pain and/ or damage can cause problems in your legs. You may not feel any symptoms to those other areas until a day or two later, but these are all parts of your body that could get worse over time and require additional medical treatment. It is important in a workers’ compensation claim to document every part of the body that was affected by the accident no matter how small it may seem. It is more difficult to try and convince a Commissioner or insurance company that another body part was also injured in the same accident if there is no documentation of it within a few days of the accident.

What’s In The Injury Report Matters

This rule is important to remember when filling out your accident report at work, your workers’ compensation claim form, and any forms you are given at every medical office you visit after the accident. In our practice, we frequently read emergency room reports where an injured body part is left out or the wrong body part is documented. We all know hospitals are busy places and not everything is always documented with 100% accuracy, but insurance companies will use this to discredit your injury or the cause of your injury. It is important for you to check that how the accident occurred and that all injuries are clearly described and documented. Make sure to tell the medical professional you are dealing with every ache, pain and/or discomfort that you are feeling as a result of the accident.

Contact Us With Questions

If you have any questions about a new pain or problem that developed after your injury it is always best to contact an attorney. Our attorneys have years of experience and know the right questions to ask to ensure that you receive the full coverage, you are entitled to for your injuries.

Workers’ Compensation Claims Process - How long does it take to get a hearing and what is a “consideration date?

Friday, July 14, 2017

One of the most common questions I receive from clients concerns how long it takes to get a hearing before the Maryland Workers’ Compensation Commission. As with any court or judicial body, the Commission sets its own schedule and the claimants and attorneys appearing before it are subject to that schedule. Generally speaking, however, it is a safe assumption that your hearing will be scheduled within three to four months from the date you file your claim or request a hearing. This can vary based on your hearing venue. For example, hearings are scheduled much quicker in Baltimore or Beltsville (the hearing sites with a higher volume and where hearings are held more frequently), than in La Vale or Cambridge (where hearings are held less frequently based on a lesser volume).

What is the “Consideration Date?”

The claim process begins when you file an “Employee Claim Form” with the Commission. This document asks you basic demographic and injury-specific questions. Once this is submitted, the Commission will send a Notice of Claim to your employer and your employer’s workers’ compensation insurance carrier, referred to as the insurer. On the bottom-right of this Notice of Claim, you will find a “Consideration Date,” which is typically about a month from the date your original Employee Claim Form was filed. Your employer and insurer have until this date to either accept or contest your claim. If they contest the claim, they will file Contesting Issues with the Commission and you will have to wait for a hearing to present the evidence of your work-related injury or illness. You cannot request a hearing on your own behalf until after the “consideration date,” has passed. That’s why it is so important to file your claim as soon as possible.

My Employer and Insurer filed Contesting Issues; what next?

When your employer and insurer file Contesting Issues, they are, in effect, opposing the claim until the Commission can hold a hearing to determine the validity of your claim. As stated above, this will typically be scheduled anywhere between three to four months from the date your claim is initially filed. At this first hearing, you will be called upon to testify and present evidence of your work-related injury or illness, including medical records supporting your claim. After the hearing, the Commissioner will decide whether or not your injury or illness is covered by the workers’ compensation laws of Maryland. However, up until that time, you will not be able to recover any workers’ compensation benefits such as temporary total disability. You may or may not receive medical coverage. For this reason, it is all the more urgent that you consult with an attorney to determine your options and to prepare for this hearing.

How can my hearing be scheduled on an emergency basis?

In some circumstances, you can request the Commission to schedule your hearing sooner based on an “emergency” situation. For example, if you are unable to work on account of your injury or illness and have received collection notices on past-due bills or if you require emergency medical treatment, then the Commission may schedule your hearing sooner, within a matter of weeks rather than months. However, you must submit documents to support the urgency and these requests are not always granted.

If you have any questions or require assistance with your work-related injury or illness, please do not hesitate, contact Matthew Engler, Esq. today at 301-740-3322 or mengler@bsgfdlaw.com.

Workers’ Compensation and FMLA

Tuesday, June 27, 2017

If you find yourself injured on the job, and are required to miss work while you recover, you may be concerned about whether your job will still be waiting for you when you are able to return. Certain employees have federal protections available to them, in addition to their workers’ compensation benefits, which they may not be aware of.

What is FMLA?

Employees who suffer work related accidents may be covered under the Maryland Workers’ Compensation Act. In addition those same employees, who sustain what is known as a “serious health condition”, are entitled to federal protections under the Family Medical Leave Act, or FMLA. The most important safeguards available to injured workers require that employers provide twelve (12) weeks of job-protected unpaid leave and continue to provide group health benefits during that twelve (12) week period. Put another way, FMLA holds your job open for twelve (12) weeks, if you are injured on the job and qualify for FMLA.

How Do I Know if I Qualify for FMLA?

If you work for a private employer who has at least fifty (50) employees, a federal, state ,or local government, or an elementary or secondary school (regardless of the number of employees), you are eligible for FMLA in addition to workers’ compensation benefits as long as you suffer a “serious health condition” in the course of your employment.

If you do work for a covered employer, you must have worked for that employer for at least twelve (12) months in order to qualify for job protection through FMLA, even if that work is seasonal.

A “serious health condition” includes a work injury where (1) you required an overnight stay in a hospital or medical facility; or (2) you were off work for more than three days and required ongoing medical treatment (such as multiple doctors’ appointments and/or follow up care).

What is the Difference Between FMLA and Workers’ Compensation?

Pay: Workers’ Compensation entitles you to payment of temporary total or partial disability benefits while you are off work and the payment of all reasonable treatment for your compensable work related injury. FMLA, however, is unpaid leave, which ensures that, as long as you return to work within the twelve (12) week period, you are entitled to return to the same or equivalent job. So, if you suffer a “serious health condition” on the job you may be entitled to payment through workers’ compensation, while your job is held open by FMLA.

Medical Expenses and Health Insurance: FMLA requires that covered employers continue to pay health insurance as if you were still working. However, this does not include the medical expenses that you incur as a result of your work related accident. This is not usually a concern since Workers’ Compensation gives you the lifetime right to request payment of any medical treatment which is reasonable, necessary, and related to the on the job accident. In other words, if you injure your knee on the job and require a knee replacement surgery as a result of that accident, you have the right to request that the medical expenses and recovery from that surgery be paid for under Workers’ Compensation. If you catch a cold while out of work for that knee replacement surgery during the twelve (12) week FMLA period, you will still be able to see your primary care physician under your employer provided health insurance and the job will be held open for you.

Navigating how Workers’ Compensation interacts with the Family Medical Leave Act can be complicated. In addition, workers may not realize the rights that they have under the Maryland Workers’ Compensation Act and Federal FMLA. If you are injured on the job and require an extended leave of absence to recover from your injury, please contact Natalie Whittingham.

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