Many injuries – and the subsequent surgeries and treatments you need – are quite painful. Prescribing painkillers or sending you to pain specialists is often normal in the course of treatment for these injuries, and Workers’ Compensation is supposed to cover it.
Workers’ Compensation pays medical benefits in two general ways: either you settle your case and they give you all of the money for you to pay for your ongoing medical needs, or you are granted benefits, and they pay as the care arises. If they paid your benefits directly, you usually do not get a check; it goes straight to your provider. There are also limits on what care you can get in some cases.
Contact Cardamone Law’s Certified Pennsylvania Workers’ Compensation Lawyers for help with your claim by calling (267) 651-7945.
How Workers’ Comp Pays Medical Benefits
Medical benefits are usually paid from your employer’s Workers’ Compensation carrier directly to the care provider. This usually applies for emergency care, care while your case is pending, and care after your claim for benefits is accepted.
As treatments arise, your provider bills the insurance carrier, and they pay. There are some exceptions to this, though.
How a Settlement Affects Medical Benefits Under Workers’ Comp
If you settle your case, then the insurance carrier stops paying for your treatments and gives you all of the money you agreed to instead. This amount needs to be enough to cover your ongoing lost wages for the full period of disability, plus the cost of any ongoing medical care you need and any unpaid services you already received.
Sometimes settlements cover just the lost-wage benefits, and medical care costs continue to be paid as they come up. You only get the money to pay for your care if you also settle the medical benefits side of the case.
Our Pennsylvania Workers’ Compensation carriers should review your case before you accept any settlements to see that there is enough in the settlement to cover your ongoing care needs, taking special attention to speak with experts about what your pain management journey may look like.
What Pain Management Care is Covered Under Workers’ Compensation?
Workers’ Comp covers all medical care you need for your injury. Questions of what care is needed are usually resolved by your treating physician.
Covered Doctors
In the first 90 days of care, your treating physician usually has to come from a list of “panel doctors” your employer or their insurance carrier should have made available. This often includes a range of doctor types, but pain management and palliative care specialists might not be on the list.
If you do need a specialist that isn’t listed, you can choose a doctor from outside the list. After the first 90 days pass, you can also choose your own doctor.
Types of Care
Pain management care can come in a few forms:
- Ice and heating pads, which usually aren’t covered
- Over-the-counter medication like acetaminophen and ibuprofen, which usually isn’t covered unless you need prescription-strength pills or liquids
- IV painkillers, usually administered in the hospital after surgery
- Oral painkillers, typically narcotics and opioids (e.g., codeine, Percocet, Vicodin)
- Prescription muscle relaxers (e.g., Valium)
- Patches and shots (e.g., fentanyl patches, cortisone injections)
- Procedures to reduce or eliminate pain
- Physical therapy and rehabilitation.
There may also be opportunities for other care, though it might not be “medical.” This is especially common for chronic pain after an injury and includes treatment like chiropractic care or acupuncture.
Most pain relief care should be covered if it is performed by a provider licensed in Pennsylvania and is prescribed by a licensed provider. If there are doubts about coverage, we can challenge denials in court.
Is Medical Marijuana Covered Under Workers’ Comp for Pain Relief?
Many of the most important pain relief drugs are narcotics, opioids, and other Schedule I and Schedule II drugs. Workers’ Comp often covers these with a prescription, but medical marijuana coverage is not the same.
Pennsylvania law allows medical marijuana to be used as treatment for many issues, including pain relief. However, marijuana is still illegal at the federal level.
Some insurance carriers have problems covering medical marijuana outright, and may instead require you to use your medical marijuana card to purchase the medication at a dispensary, then they will reimburse you for the cost.
This is an extra step, but medical marijuana should typically be paid for at the end of the day.
What Pain Management Isn’t Covered Under Workers’ Comp?
Some basic pain management things are not going to be covered in most cases. For example, Tylenol/Advil, ice, and heating pads probably are not going to be covered, nor will other over-the-counter care costs. However, some doctors will be willing to provide you with these things at your appointment and bill insurance. Prescription-strength versions of OTC painkillers can also be prescribed.
Doctors may also suggest you do things on your own, like stretch, perform light workouts, and stay active. Much of this will be part of your physical rehab and physical therapy – which should be covered – but they may suggest you work on your own, too. However, there is usually nothing for insurance to cover here.
Similarly, activities like meditation may be helpful for relieving pain, but Workers’ Comp is unlikely to cover meditation sessions unless provided as part of some other care (e.g., chiropractic care or physical therapy).
However, therapeutic massages might be covered along with chiropractic care, acupuncture, and other traditional medicine treatments.
How Do You Get Pain Treatments Approved?
Most care will be billed straight to your employer’s insurance carrier, and it will be up to them to pay it. They may want to refuse certain coverages, but they may have to go through a formal process to be able to say no to covering certain care.
A Utilization Review can be scheduled to have an outside care provider assess whether the medical care is reasonable and necessary. If they find it is, your insurance carrier will have to cover it. There are appeals cases that have resolved what is reasonable and necessary in certain cases, so we may be able to reference these precedents to argue your similar treatments should be covered.
Call Our Workers’ Compensation Lawyers in Pennsylvania
Call Cardamone Law’s Altoona, PA Workers’ Compensation lawyers at Cardamone Law at (267) 651-7945 for a free case review.
