In Pennsylvania, once a worker is injured on the job and his or her claim is accepted by his employer’s workers’ compensation insurance carrier, the injured worker should have no cause to pay for medical treatment. Instead, the doctor, hospital, or other medical provider is legally required to bill a workers’ compensation insurance company directly and may not seek payment from an injured worker. Once an injured worker begins to receive medical treatment for his or her injury, illness, or condition, how do the resulting medical bills get paid?
First, a summary of how an injured worker begins any type of medical treatment. Injured workers have the option of choosing their own health care provider to treat a work injury unless their employer accepts the claim and has posted a list of six or more physicians or health care providers in the workplace. Thus, employers may direct an injured worker to any of six providers that the employer approves for an initial period.
Injured workers are required to visit a provider on the list for initial treatment and continue treatment with this provider or another on the list for 90 days following the first visit. Workers are free to choose any provider on the list and may not be directed by an employer to any specific provider on the list.
The mandate under the Pennsylvania Workman’s Comp Act that an injured worker must only receive treatment from a “company doctor” for 90 days from the first visit only if the employer creates a list of at least six designated health care providers only applies if the employer provides the employee with written notification of the employee’s rights and duties, and obtains the employee’s written acknowledgment of being informed of these rights and duties. If an employer fails to provide this notice and does not obtain the employee’s signed acknowledgment, the injured worker may receive treatment from any doctor or provider.
Doctors, hospitals, and other licensed healthcare providers are paid for their services based upon a fee schedule that is adjusted annually. It is important to note that injured workers are never required to make any type of co-payment or pay any other fee for medical care related to a work injury. Instead, providers of medical treatment must submit their bills to the employer’s insurance carrier for payment.
When medical services are properly billed and the proper forms have been received, an insurance company or other party responsible for payment has thirty (30) days to process the bill. If a medical provider does not receive timely or correct payment, an Application for Fee Review may be filed.
If a provider complains that it has not been paid and a claim has been approved or accepted, the problem is probably the result of a bureaucratic delay, mistake, or miscommunication. If medical bills are unpaid because the claim has been denied, then it is likely that further action must be taken. Whether this action is a letter from a physician stating that an injury is work-related, gathering more evidence, or a review of the claim’s viability, consulting with an experienced workers’ compensation attorney is a good idea at this time.
It may be more difficult to get prescription medication paid for since some pharmacies are unwilling to bill a workers’ compensation insurance company directly. Also, many pharmacies will not fill prescription orders unless payment has been pre-approved. For workers whose claim has been denied and have no health insurance, a specialty workers’ comp pharmacy may fill prescriptions while a worker’s compensation case is pending.
If a worker has health insurance and his or her claim has been denied, Pennsylvania law requires that the worker’s health insurance company pay any medical bills related to a work injury. An injured worker or his or her attorney should send the health insurance company a copy of the notice of the denial of benefits if it requires proof that the workers’ compensation insurance company refuses to pay medical bills related to a worker’s compensation claim.
The process for filing and receiving approval of workers’ compensation claims in Pennsylvania is complicated. Claimants are required to provide a long list of information in the form of medical records and other necessary documentation. This information must be collected, organized, and presented within certain procedures and deadlines. Powell Law has represented injured workers for 115 years and has a distinguished reputation throughout northeastern Pennsylvania for adhering to the highest standards in serving those injured on the job. Contact Powell Law at (570) 961-0777. The consultation is FREE, and you don’t pay unless we win!