In addition to representing injured workers in Pennsylvania, we represent doctors and other medical providers who need their medical bills paid by Workers’ Comp insurers.
The Pennsylvania Workers’ Compensation Act has specific requirements that must be met in order for work-related medical treatment to be paid by an insurer. When providers file the appropriate forms and meet the applicable billing deadlines, Workers’ Comp should pay all reasonable and necessary medical expenses, leaving you with no out-of-pocket medical costs yourself. Medical bills only get paid after Workers’ Compensation claims get approved, so do not wait long at all to report the injury to an employer and enlist our lawyers to handle your recovery.
Call Cardamone Law at (267) 651-7945 for help with your case from our Certified Pennsylvania Workers’ Compensation Lawyers.
Does Your Claim Need to Be Approved Before Workers’ Comp Pays Medical Bills in Pennsylvania?
Before physicians can begin billing the Workers’ Compensation carrier directly and receive payment for all reasonable and necessary medical expenses, the carrier must approve the claim. Don’t waste any time after suffering an occupational injury, and report it to your employer immediately. They should then promptly to inform their insurance carrier, which then has only 21 days to review your claim and give you an answer.
While you are waiting for your claim to be approved, don’t pay any medical bills associated with the workplace injury without talking to your lawyer about it first. For your initial treatment, other than possibly going to the emergency room, you must see a physician approved by your employer. You can inform them you are seeking Workers’ Comp benefits, and that you won’t be covering any expenses out-of-pocket yourself.
To avoid medical bills building up and causing any undue stress, prioritize filing your Workers’ Compensation claim in Pennsylvania. Prompt filing can increase your chances of bringing a successful claim, one that covers all medical expenses and provides some compensation for lost wages.
What Deadlines Do You Have to Follow for Workers’ Comp to Pay Medical Bills?
All treatments must be billed on the proper forms within 30 days and be accompanied by the corresponding medical reports. Any failure to meet the billing requirements in Pennsylvania will be used as a means for the insurer to avoid payment.
You must also file the general deadline for seeking Workers’ Compensation benefits to ensure medical bills get paid. Pennsylvania gives employees 120 days to report injuries to an employer to get Workers’ Comp, but you are usually expected to file within 21 days. There’s no need to wait that long, however, as delaying your claim could compromise it, even if you seek damages before the ultimate deadline.
What Medical Bills Should Workers’ Comp Pay in Pennsylvania?
Workers’ Compensation should cover all the medical expenses you incur from a work-related injury in Pennsylvania. Medical treatment must be both reasonable and necessary for Workers’ Compensation to cover it, and our attorneys can help if a carrier questions the necessity of certain treatments.
Workers’ Compensation should start by paying medical bills generated from you seeking treatment from an employer-approved doctor. Unless it is an emergency, you need an unlisted specialist, or you are getting a second opinion on surgical needs, you must use a doctor from your employer’s list of approved physicians for initial care. If you do not follow this rule in the first 90 days of care, Workers’ Comp may refuse to cover your initial medical damages.
Once 90 days pass after an accident, you can see a doctor of your choosing. Your employer’s Workers’ Compensation carrier does not need to approve this physician. It should proceed to cover any and all reasonable and necessary medical expenses from their treatment, provided they are licensed and billed correctly.
If the carrier questions whether a specific procedure and its cost were reasonable or necessary, we can provide them with statements from your physicians confirming the importance of this care for you to reach maximum medical improvement, whatever that may look like for you.
What Forms and Reports Do You Need to Submit so Workers’ Comp Pays Medical Bills?
Please be advised that any medical bills for work-related treatment must be made on either an HCFA form 1500 or the UB92 (HCFA form 1450), or any successor forms, required by HCFA for submission of Medicare claims. Until a medical provider submits bills on one of these forms, insurers are not required to pay for the treatment billed.
Furthermore, providers who treat injured employees are required to submit periodic medical reports to the employer, commencing 10 days after treatment begins and at least once per month thereafter, as long as treatment continues. If the employer is covered by an insurer, the provider shall submit the report to the insurer.
The medical reports referenced above shall be submitted on a form prescribed by the Bureau of Workers’ Compensation. The report shall include the history, a description of the treatment and services rendered, the physical findings, and the prognosis, including whether the claimant can return to pre-injury work without limitations.
Reports are not required to be submitted for months in which no medical treatment has been rendered. Once again, if a provider does not submit the required medical reports on the prescribed form, the insurer is not obligated to make payment.
In summary, you must use the proper HCFA form and submit it along with the bill and a legible, detailed medical report for each month in which treatment is rendered to receive payment.
How Quickly Does Workers’ Comp Have to Pay Medical Bills?
Payments for treatment must be made within 30 days of receipt of the bill and report submitted by the provider.
Insurers shall supply a written explanation of benefits (EOB) to the provider, describing the calculation of payment of medical bills submitted by the provider. If an insurer fails to pay the entire bill within 30 days of receipt of the required bills and medical reports, interest shall accrue on the due and unpaid amounts at 10% per annum.
How Do You Handle Medical Bill Disputes with Workers’ Comp?
A provider who has submitted the required bills and reports to an insurer and disputes the amount or timeliness of the payment made by an insurer, shall have standing to seek review of the fee by the Bureau.
Providers seeking review shall file the original and one copy of a form prescribed by the Bureau as an application for Fee Review, and shall be filed no more than 30 days following notification of a disputed treatment or 90 days following the original billing date of the treatment, whichever is later.
A copy of the application and the attached documents shall be served upon the insurer, with a proof of service.
Can Providers Bill Claimants if Workers’ Comp Doesn’t Pay All Medical Bills?
Pennsylvania does not allow “balance billing,” even when Workers’ Compensation carriers are slow to pay bills.
Because Pennsylvania prohibits balance billing, a provider may not hold an employee liable for costs related to care or services rendered in connection with a compensable workplace injury.
A provider may not bill for, or otherwise attempt to recover from the employee, the difference between the provider’s charge for treatment and the amount paid by an insurer. This holds true for treatment determined to be unreasonable or unnecessary.
Why Might Workers’ Comp Refuse to Pay Medical Bills?
One of the hardest parts of dealing with an injury is navigating through the medical bills, an extra expense on top of all the mental and physical strain. In most cases, Pennsylvania offers great relief in the form of coverage for reasonable and necessary treatment of the injury. However, it is not always as simple as that to get complete coverage on the medical bills in a Pennsylvania workers’ compensation case.
There are several reasons a medical bill goes unpaid or denied, including the following:
- The doctor’s office did not send the bill on the right forms
- The treatment does not match the description of the accepted injury
- The insurance company wants to make your life difficult
Each situation is different, and the remedy will depend on the reason. For example, if your insurance company is refusing to pay the bill, your Workers’ Compensation attorney may want to review the controlling doc to see if the treatment is covered under the injury. Your Pennsylvania Workers’ Compensation attorney will go through the document and your situation to determine the reason and come up with a solution accordingly.
How Long Should Workers’ Comp Pay Medical Bills?
In Pennsylvania, Workers’ Compensation should keep covering medical bills associated with an occupational injury or illness for as long as you incur them. It doesn’t matter if the claimant resumes working in some capacity; their employer’s carrier should continue to pay their medical bills to treat the initial injury or condition.
There’s no set time limit on how long claimants can receive medical benefits in Pennsylvania. As long as we can prove the treatments are reasonably priced, medically necessary, and still related to a workplace injury, the insurance carrier must keep covering bills sent by your physicians.
Tell our lawyers if Workers’ Comp stopped paying your medical bills or other benefits prematurely.
Our Lawyers Can Help with Your Workers’ Compensation Case in Pennsylvania
Call Cardamone Law at (267) 651-7945 for a free case review from our Philadelphia, PA Workers’ Comp lawyers.
