TITLE 34
LABOR AND INDUSTRIAL RELATIONS
Section 9. Workers' Compensation, 34-9-1 through 34-9-432.
ARTICLE 6
PAYMENT OF COMPENSATION
34-9-208. Certification of managed health care providers.
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Any health care provider or group of medical service providers may make written application to the board to become certified to provide managed care to injured employees for injuries and diseases compensable under this chapter.
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Each application for certification shall be accompanied by a reasonable fee prescribed by the board.A certificate is valid for such period as the board may prescribe unless sooner revoked or suspended.
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Application for certification shall be made in such form and manner and shall set forth such information regarding the proposed plan for providing services as the board may prescribe.The information shall include, but not be limited to:
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A list of the names of all individuals who will provide services under the managed care plan, together with appropriate evidence of compliance with any licensing or certification requirements for that individual to practice in this state;
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A description of the times, places, and manner of providing services under the plan;
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A description of the times, places, and manner of providing other related optional services the applicants wish to provide; and
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Satisfactory evidence of ability to comply with any financial requirements to ensure delivery of service in accordance with the plan which the board may prescribe.
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The board shall certify health care providers or a group of medical service providers to provide managed care under a plan if the board finds that the plan:
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Proposes to provide services that meet quality, continuity, and other treatment standards prescribed by the board and will provide all medical and health care services that may be required by this chapter in a manner that is timely, effective, and convenient for the employee;
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Provides appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service;
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Provides adequate methods of peer review, service utilization review, and dispute resolution to prevent inappropriate or excessive treatment, to exclude from participation in the plan those individuals who violate these treatment standards, and to provide for the resolution of such medical disputes as the board considers appropriate;
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Provides a program involving cooperative efforts by the employees, the employer, and the managed care organization to promote consultative and other services that will contribute to workplace health and safetyand early return to work for injured employees;
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Provides a timely and accurate method of reporting to the board necessary information regarding medical and health care service costs and utilization to enable the board to determine the effectiveness of the plan; and
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Complies with any other requirement the board determines is necessary to provide quality medical services and health care to injured workers at a reasonable cost.
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The board shall refuse to certify or may revoke or suspend the certification of any health care provider or group of medical service providers to provide managed care if the members of the board find that:
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The plan for providing medical or health care services fails to meet the requirements of this Code section; or
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Service under the plan is not being provided in accordance with the terms of a certified plan.
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Utilization review, quality assurance, and peer review activities pursuant to this Code section shall be subject to the review of the board or the board's designated representatives.Data generated by or received in connection with these activities, including written reports, notes, or records of any such activities, or of the board's review thereof, shall be confidential and shall not be disclosed by the board except as considered necessary by the board in the administration of this chapter.The board may report professional misconduct to an appropriate licensing authority.
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No data generated by utilization review, quality assurance, or peer review activities pursuant to this Code section or the board's review thereof shall be used in any action, suit, or proceeding except to the extent considered necessary by the board in the administration of this chapter.
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A person participating in utilization review, quality assurance, or peer review activities pursuant to this Code section shall not be examined as to any communication made in the course of such activities or the findings thereof, nor shall any personnel be subject to an action for civil damage for affirmative actions taken or statements made in good faith.
(Code 1981, §34-9-208, enacted by Ga. L. 1994, p. 887, § 12.)
Law reviews.
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For annual survey on workers' compensation, see 64 Mercer L. Rev. 341 (2012).
JUDICIAL DECISIONS
Cited in
MARTA v. Reid, 282 Ga. App. 877, 640 S.E.2d 300 (2006).
34-9-220. Period of incapacity preceding payment of compensation.
No compensation shall be allowed for the first seven calendar days of incapacity resulting from an injury, including the day of the injury, except the benefits provided for in Code Section 34-9-200; provided, however, that, if an employee is incapacitated for 21 consecutive days following an injury, compensation shall be paid for such first seven calendar days of incapacity.
(Ga. L. 1922, p. 185, § 2; Code 1933, § 114-401; Ga. L. 1963, p. 141, § 3; Ga. L. 1990, p. 1409, § 10.)
JUDICIAL DECISIONS
Date of a gradually-acquired injury
should be set at the first time the injury becomes extensive enough either to prevent the claimant from working or to constitute a disability as itemized in the Workers' Compensation Act (see now O.C.G.A.
§
34-9-1 et seq.). Employers Mut. Liab. Ins. Co. v. Shipman, 108 Ga. App. 184, 132 S.E.2d 568 (1963).
Burden on employer.
- Because an employee used the employee's vacation, personal, and sick leave time because the employee was unable to work due to a compensable injury, and the employee was unaware that the employee was entitled to workers' compensation benefits, after determining that the employee was entitled to temporary total disability income benefits, a credit to the employer was denied under O.C.G.A.
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34-9-243(b), as the employer failed to meet its burden of showing that it was entitled to such a credit for employer-funded payments under a disability plan, wage continuation plan, or disability insurance policy, or that the employee was paid the employee's regular wages pursuant to O.C.G.A.
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34-9-220. Glisson v. Rooms To Go, 270 Ga. App. 689, 608 S.E.2d 50 (2004).
Evidence supported denial of benefits.
- Worker was properly denied workers' compensation benefits and terminated from employment for failing to return from a leave of absence because evidence supported the findings that the worker recovered from the chemical fume exposure incident based on a family doctor releasing the worker to return to work with no restrictions and that the pneumonia the worker suffered was unrelated to the exposure incident. Royal v. Pulaski State Prison, 324 Ga. App. 275, 750 S.E.2d 179 (2013).
Cited in
Langston v. Maryland Cas. Co., 43 Ga. App. 854, 160 S.E. 823 (1931); New York Indem. Co. v. Allen, 47 Ga. App. 657, 171 S.E. 191 (1933); New Amsterdam Cas. Co. v. McFarley, 191 Ga. 334, 12 S.E.2d 355 (1940); Pittsburgh Plate Glass Co. v. Bailey, 111 Ga. App. 609, 142 S.E.2d 388 (1965); Harris v. Atlanta Coca-Cola Bottling Co., 128 Ga. App. 193, 196 S.E.2d 159 (1973).
RESEARCH REFERENCES
ALR.
- Remedy for enforcement of award made under Workmen's Compensation Act in case of injury to public officer or employee, 10 A.L.R. 190.
Workmen's compensation: statutory phrase "incapacity for work" or the like, as including inability to obtain work following an injury, 33 A.L.R. 115.
