2011 ORS § 656.313¹
Stay of compensation pending request for hearing or review
- • procedure for denial of claim for medical services
- • reimbursement
(1)(a) Filing by an employer or the insurer of a request for hearing on a reconsideration order before the Hearings Division, a request for Workers Compensation Board review or court appeal or request for review of an order of the Director of the Department of Consumer and Business Services regarding vocational assistance stays payment of the compensation appealed, except for:
(A) Temporary disability benefits that accrue from the date of the order appealed from until closure under ORS 656.268 (Claim closure), or until the order appealed from is itself reversed, whichever event first occurs;
(B) Permanent total disability benefits that accrue from the date of the order appealed from until the order appealed from is reversed;
(C) Death benefits payable to a surviving spouse prior to remarriage, to children or dependents that accrue from the date of the order appealed from until the order appealed from is reversed; and
(D) Vocational benefits ordered by the director pursuant to ORS 656.340 (Vocational assistance procedure) (16). If a denial of vocational benefits is upheld by a final order, the insurer or self-insured employer shall be reimbursed from the Workers Benefit Fund pursuant to ORS 656.605 (Workers Benefit Fund) for all costs incurred in providing vocational benefits as a result of the order that was appealed.
(b) If ultimately found payable under a final order, benefits withheld under this subsection shall accrue interest at the rate provided in ORS 82.010 (Legal rate of interest) from the date of the order appealed from through the date of payment. The board shall expedite review of appeals in which payment of compensation has been stayed under this section.
(2) If the board or court subsequently orders that compensation to the claimant should not have been allowed or should have been awarded in a lesser amount than awarded, the claimant shall not be obligated to repay any such compensation which was paid pending the review or appeal.
(3) If an insurer or self-insured employer denies the compensability of all or any portion of a claim submitted for medical services, the insurer or self-insured employer shall send notice of the denial to each provider of such medical services and to any provider of health insurance for the injured worker. Except for medical services payable in accordance with ORS 656.247 (Payment for medical services prior to claim acceptance or denial), after receiving notice of the denial, a medical service provider may submit medical reports and bills for the disputed medical services to the provider of health insurance for the injured worker. The health insurance provider shall pay all such bills in accordance with the limits, terms and conditions of the policy. If the injured worker has no health insurance, such bills may be submitted to the injured worker. A provider of disputed medical services shall make no further effort to collect disputed medical service bills from the injured worker until the issue of compensability of the medical services has been finally determined.
(4) Except for medical services payable in accordance with ORS 656.247 (Payment for medical services prior to claim acceptance or denial):
(a) When the compensability issue has been finally determined or when disposition or settlement of the claim has been made pursuant to ORS 656.236 (Compromise and release of claim matters except for medical benefits) or 656.289 (Orders of Administrative Law Judge) (4), the insurer or self-insured employer shall notify each affected service provider and health insurance provider of the results of the disposition or settlement.
(b) If the services are determined to be compensable, the insurer or self-insured employer shall reimburse each health insurance provider for the amount of claims paid by the health insurance provider pursuant to this section. Such reimbursement shall be in addition to compensation or medical benefits the worker receives. Medical service reimbursement shall be paid directly to the health insurance provider.
(c) If the services are settled pursuant to ORS 656.289 (Orders of Administrative Law Judge) (4), the insurer or self-insured employer shall reimburse, out of the settlement proceeds, each medical service provider for billings received by the insurer or self-insured employer on and before the date on which the terms of settlement are agreed as specified in the settlement document that are not otherwise partially or fully reimbursed.
(d) Reimbursement under this section shall be made only for medical services related to the claim that would be compensable under this chapter if the claim were compensable and shall be made at one-half the amount provided under ORS 656.248 (Medical service fee schedules). In no event shall reimbursement made to medical service providers exceed 40 percent of the total present value of the settlement amount, except with the consent of the worker. If the settlement proceeds are insufficient to allow each medical service provider the reimbursement amount authorized under this subsection, the insurer or self-insured employer shall reduce each providers reimbursement by the same proportional amount. Reimbursement under this section shall not prevent a medical service provider or health insurance provider from recovering the balance of amounts owing for such services directly from the worker, unless the worker agrees to pay all medical service providers directly from the settlement proceeds the amount provided under ORS 656.248 (Medical service fee schedules).
(5) As used in this section, health insurance has the meaning for that term provided in ORS 731.162 (Health insurance). [1965 c.285 §41; 1979 c.673 §1; 1981 c.535 §8; 1981 c.854 §22; 1983 c.809 §2; 1990 c.2 §23; 1993 c.521 §1; 1995 c.332 §38; amendments by 1995 c.332 §38a repealed by 1999 c.6 §1; 1999 c.6 §11; 2001 c.865 §13a; 2005 c.588 §4; 2009 c.35 §4; 2011 c.80 §1]