Sedgwick Prevails in Dispute Over Unpaid Prescription Charges for Louisiana Claimant
Reversing a decision of the state’s Office of Workers’ Compensation (OWC), a Louisiana appellate court held the State was not responsible for almost $48,000 in unpaid prescription bills related to medications supplied to an injured state employee by the Injured Workers’ Pharmacy (IWP) where the State’s third-party administrator, Sedgwick, notified the employee and IWP in July 2016, that it would no longer authorize payment for medications filled directly through IWP, since the employee had been issued a prescription card by Sedgwick to fill prescriptions at numbers of local pharmacies [Corona v. Louisiana Corr. Inst. for Women, 2020 La. App. LEXIS 1586, 2020 0260 (La.App. 1 Cir. 11/06/20)]. The appellate court indicated its decision was consistent with the state supreme court’s Burgess decision [discussed below], in which the high court ruled that the choice of pharmacy in a workers’ compensation case belongs to the employer.
Background
In September 1998, Corona sustained work-related injuries during her employment with the Louisiana Correctional Institute for Women, a subdivision of the State of Louisiana (“State”). As relevant here, she filed a disputed claim seeking payment by the State for unpaid invoices for prescription medication obtained through IWP. Following a trial, the OWC found that the State was responsible for the payment of medication prescriptions in the amount of $43,807.38, dispensed and billed by the IWP, together with legal interest and costs.
Sedgwick’s Prescription Card
On appeal, the State maintained that it had no liability for the IWP bills because Ms. Corona and IWP were notified by Sedgwick Claims Management Services, Inc. (Sedgwick), in a letter dated July 14, 2016, that Sedgwick would no longer authorize payment for medications filled directly through IWP, since Ms. Corona had been issued a prescription card by Sedgwick to fill prescriptions.
The State also contended that the issue was decided in Burgess v. Sewerage & Water Board of New Orleans, 16-2267 (La. 6/29/17), 225 So.3d 1020, 1028, wherein the Louisiana Supreme Court held that the injured employee does not have a right to choose a specific prescription provider [to see my earlier discussion of Burgess, click here]. The State argued, therefore, that pursuant to Burgess, and the statutes discussed therein, the State was obligated to pay no more than $750 for nonemergency care, and the OWC erred as a matter of law when it ruled to the contrary. In the instant case, the appellate court found that the supreme court’s holding in Burgess was broad enough to encompass the prescription benefit service under the facts of the case.
The appellate court noted testimony in which Sedgwick representatives indicated that Ms. Corona had been provided with a prescription card, which entitled her to fill prescriptions in a timely manner at a large selection of local pharmacies without incurring any out-of-pocket expenses and that IWP had been warned on several occasions to bill through a prescription service, but it had continued to supply medications directly to Ms. Corona and bill the State. The court noted also that Sedgwick had paid the $750 due for nonemergency diagnostic testing or treatment pursuant to LSA-R.S. 23:1142B(1)(a).
State of Louisiana Not Required to Pay for Disputed Prescriptions
The appellate court concluded, therefore, that because the State notified Ms. Corona and IWP that it did not consent to the dispensing of prescription medication by IWP directly to Ms. Corona after July 14, 2016, any ongoing consent to or authorization of dispensing of prescriptions by IWP directly to Ms. Corona was terminated after that date. Therefore, the State was not responsible for any unpaid invoices, in excess of the $750 previously paid, after July 14, 2016, that were not submitted through the prescription benefit service. The OWC’s decision was accordingly reversed.