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.

The Money

Recently, a prospective client called me and we spoke about her workers’ compensation case. During the course of our talk, she said “it’s not about the money”.  While this is a trendy and popular thing to say- often times as a defense mechanism to ward off unfair images of greed-it really is misplaced in a Pennsylvania Workers’ Compensation matter.

You see, it IS about money. The Pennsylvania Work Comp Law provides wage loss and medical benefits for injured workers who are injured in the course and scope of their employment. The entire purpose of the Act is to prevent injured workers from becoming financially destitute after sustaining a work-related injury.

It’s common to hear sound bites in the media, in various legal contexts, such as “It’s about justice” or “It’s the principle”.  While those philosophical notions of fairness are an overarching theme of the law in general, when you cut to the chase in a PA Work Comp arena, they don’t get you very far. Yes, if someone is injured on the job, and if the insurer denies their claim, then the injured worker wants “justice”, but justice equates to the employer and insurer paying the owed benefits. The benefits come directly to the injured worker in the form of a check equaling the loss of earning power- and to the medical providers in the form of payment for treatment rendered.

When my clients workers’ comp checks come two weeks late and their landlord is threatening to evict them, it’s about the money. When my clients have a tuition bill on their kitchen counter but their employer denied their work comp claim, it’s about the money. When my clients, after building up their credit over decades of timely payments, have their credit destroyed because the workers’ compensation carrier fails to pay for the medical bills, it’s about the money.

My clients don’t want a hollow victory. They want the benefits afforded to them by law which enable them to continue paying their bills, putting food on the table, and educating their children. There is nothing wrong with believing that “it’s all about the money”.

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.

What About Out-of-Pocket Medical Costs?

If you have adequate proof that you incurred such expenses, have receipts/cancelled checks/documentation, and can show that the expenses relate to your accepted work injury. Employers often defend these claims, holding that Claimant didn’t present enough evidence linking the receipts with the accepted injury. The Pennsylvania Workers’ Compensation Act has technical requirements on many topics. You shouldn’t try to interpret it without an attorney.

What to Do if Pennsylvania Workers’ Compensation is Denying Your Outstanding Medical Bills

One of the hardest parts of dealing with an injury is navigating through the medical bill – an extra expense on top of all the mental and physical strain. In most cases, PA workers compensation act offers a great relief in the form of coverage for reasonable and necessary treatment of the injury. However, it is always not as simple as that to get complete coverage on the medical bills in a Pennsylvania workers’ compensation case.

Common Reasons for Medical Bills Being Unpaid in PA

There are several reasons a medical bill goes unpaid or denied by the PA workers compensation. We are listing some of the common reasons below but we highly recommend that you talk to your workers compensation attorney in PA to discuss the situation in detail.

• 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 remedy will depend on the reason. For example, if your insurance company is refusing to pay the bill, your work comp 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.

Our Lawyers Can Help

Call your attorney right away if your medical bill is denied by the PA work comp. If you don’t have one yet, call our certified Allentown workers’ compensation lawyers in Pennsylvania ASAP! Our expert lawyers offer services all across PA – Allentown, Reading, Pittsburgh, Philadelphia, Reading, Kingston, Hazleton, Exton, Lancaster, or Lansdale – We are just a call away!