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How Do Medical Bills Get Paid on Workers’ Comp in Pennsylvania?

I represent injured workers in Pennsylvania. In addition, I represent doctors and other medical providers, in getting their medical bills paid by the work 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. The following will explain these technical requirements and will also address Fee Review procedures.

Deadlines

It is very important that all treatment gets billed on the proper forms, within 30 days, and with the corresponding medical reports. Any failure to meet the billing requirements under the Work Comp Act will be used as a way for the insurer to wiggle out of payment.

Forms

Please be advised that any medical bills for work-related treatment must be made on either a 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.

Further, providers who treat injured employees are required to submit periodic medical reports to the employer, commencing 10 days after treatment begins and at least one 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 for that purpose. The report shall include the history, a description of the treatment and services rendered, the physical findings and the prognosis, including whether or not 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.

Payments

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.

Balance Billing- Prohibited

A provider may not hold an employee liable for costs related to care or services rendered in connection with a compensable injury under the Act. 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.

Disputes

A provider who has submitted the required bills and reports to an insurer and who disputes the amount or timeliness of the payment made by an insurer, shall have standing to seek review of the fee (Fee Review) 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. For more information on Fee Review, see the cost containment regs at Sections 127.251 and continuing.

Fee Review

A provider who has submitted the required bills and reports to an insurer and who disputes the amount or timeliness of the payment made by an insurer, shall have standing to seek review of the fee dispute by the Bureau. Providers must apply for fee review within 30 days following notification of a disputed treatment or 90 days following the original billing date of the treatment which is the subject of the fee dispute, whichever is later. For more information, please see Section 127.252, et seq of the Medical Cost Containment Regulations under the Act.

In summary, you must use the proper HCFA form and submit this with the bill and a legible, detailed medical report, for each month in which treatment is rendered, if you want to get paid.

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