The employer or insurance carrier is responsible for all medically necessary treatment to the claimant, and payment of same, when a claim has been accepted or established by the Board as compensable. See NYCRR Section 325-1.25. When treatment is not medically necessary, the carrier can object to same using the Board-C-8.1 forms. However, if the objection is improper, the carrier will likely be found liable for significant unnecessary medical costs, and therefore face increased expenses.
The C-8.1 forms are straightforward. However, they are often resolved in favor of the medical providers because they are not properly completed or timely filed.
The C-8.1 form is divided into two Parts: A and B. Part A requires the carrier to specify the legal reason for its objection to treatment, and to provide information on its conflicting medical evidence, that is, an IME or Peer Review Report. If treatment is being objected to, the carrier must notify the claimant, provider and Board within five days of the objection. If the carrier is asserting that the basis for the objection is conflicting medical evidence, such evidence must be supplied with the C-8.1, or if already in the Board file, identified using the Board document identification number. Further, the carrier must provide proof of mailing of notice to the claimant, his attorney and his doctor. See NYCRR 300.23(d).
Part B requires the carrier to specify the legal reason for its objection to bills for treatment. In order to be effective, the C-8.1s must be filed within 45 days of submission of the bill in dispute. The carrier must complete all of the pertinent information, including the date of the bill at issue, the Board document number of said bill, date of treatment, amount of the bill, amount in dispute, and the reason for the objection. If the bill is not in the Board file, the carrier must submit a copy of it with the C-8.1. If the carrier does not object within 45 days, the carrier may be liable for payment of the full amount of the bill up to the amount allowed by the fee schedule. See NYCRR 325-1.25(c).
If the C-8.1s do not contain all of the pertinent information, and are not timely filed, the carrier’s defense of the denial becomes frail, and the Law Judge is very likely to resolve them in favor of the medical provider. In addition, it diminishes the carrier’s chances of being able to depose the claimant’s doctors on the treatment at issue, and does not support a viable record for an appeal. Moreover, when they are resolved in favor of the provider, the carrier can endure costs of expensive (and unnecessary) treatments.
There are times when a C-8.1 is not required. C-8.1s are no longer used for valuation objections such as inappropriate or excessive treatment or fees not in accordance with the fee schedule. Instead, the C-8.4 form is used for these types of objections. If a treatment request (C-4AUTH) has been previously found to be defective, the carrier would not be liable for the treatment if a C-8.1 is not filed in response to same. See for example, Saratoga Hospital, 114 NYWCLR 249 (N.Y. W.C.B. Full Board 2015). Otherwise, in order to properly object to treatment or bills, a C-8.1 must be properly completed and timely filed.