Jeana Wines

Pre-Authorization of Medical Services: New Guidance From WCD

Wines, Jeana_web_2014The WCD issued a significant decision addressing an insurer’s obligation to respond to requests for pre-authorization by medical providers. Our rules impose specific processing requirements related to elective surgery or diagnostic imaging, but adjustors frequently receive requests to pre-authorize other therapies and referrals. The provider wants to be sure they will be paid for the services they provide, yet insurers rely on having sufficient time upon receipt of bills to determine whether they are compensable. Pre-approval or guaranteeing payment for treatment that has not taken place amounts to sending a provider a blank check. In Gerardo L. Herrera, 21 CCHR 13 (2016), an insurer failed to pre-approve a referral for services recommended by the AP (and was fairly unresponsive).… Continue reading

The Latest on Independent Contractors

Wines-Gina_webI had a recent victory from the Office of Administrative Hearings setting aside an Employment Department tax assessment based on the purported employee’s status as an independent contractor. The ALJ relied on a line of recent Court of Appeals cases that have trended toward applying a much broader interpretation of the IC test than the Employment Department previously sought to apply. I anticipate additional decisions on the topic from the Court of Appeals in the coming year as they continue to provide guidance on this very fact-intensive inquiry. In most instances there are two prongs to the independent contractor inquiry. The individual must be 1) free from direction and control over the means and manner… Continue reading

The Sweet Taste of Victory

Wines-Gina_webWe always love a good win at SBH, but it is especially sweet when hard work results in important legal precedent. The Court of Appeals decision in Brumage v. ESCO Corp. became final last week, after the Supreme Court declined claimant’s Petition for Review. 248 Or.App. 399 (2012). In this case, it was undisputed that age was the major cause of claimant’s hearing loss at the time he filed his claim in 2009. Therefore, claimant sought compensation for the period of 1968 to 1994, because occupational noise was the major contributing cause during that time period. The Court of Appeals has previously held a claimant cannot tactically extract a portion of a disease to claim,… Continue reading