Adapted from Chapter 3 of The Wounded Worker: Inside the Pennsylvania Workers' Comp Maze:
In a separate page, we describe what your medical providers must do to get paid for treating your work injury. If the workers' compensation insurance company has accepted your claim, you should not pay for your medical treatment. Instead, the doctor, hospital or other medical provider is legally required to bill your workers' compensation insurance company directly and may not seek payment from you. The insurer pays only what is required under a fee schedule that limits how much a provider can receive for treatment. It is illegal for a medical provider to bill you for the difference between their charges and the amount allowed under the Pennsylvania Workers' Compensation Act.
With respect to prescription bills, it may not be so easy to find a pharmacy that is willing to bill your workers' compensation insurance company directly. To obtain prescription medicines, you may want to use a mail order prescription facility to serve your prescription needs. You can find information about mail order prescription pharmacies on the Web, or call us at 877-959-1811.
Sometimes your doctor, physical therapists or pharmacist will tell you that the insurance company has denied payment of medical bills. If your claim has been accepted, this is usually the result of a miscommunication. Get the name and phone number of the person who spoke to the insurance claims representative. Talk to this person to find out what happened. Call the claims representative to find out why the medical bills were denied. Often the bills were never submitted or the medical provider spoke with the wrong person. At other times it is not clear that the treatment was for the work injury and the insurance company needs clarification. Of course, if your medical bills are unpaid because your claim has been denied, you may have to take further action, which may be as simple as getting a medical report from a doctor stating that your condition is work related. If that doesn't’t work, you may need to hire a lawyer. Before you do so, review Chapter 6.
An employer may challenge the reasonableness and necessity of medical treatment by filing a utilization review petition within thirty days of receiving medical bills. The Bureau of Workers’ Compensation will assign the request to a Utilization Review Organization (“URO”), which will request your medical provider to send a copy of your medical records. If your physician or medical provider fails to provide copies of your medical records to the URO, the treatment will automatically be deemed unreasonable or unnecessary, so make sure your providers send the requested records. Send the URO a short note that explains how your treatment is helping you, even if you only get temporary relief. The URO will issue a report that states whether your treatment was reasonable or necessary. If the URO finds that your treatment was wholly or partly unnecessary or unreasonable, you have the right to appeal this decision to a worker’s compensation judge. You are not required to pay bills found to be unreasonable or unnecessary.
Under Pennsylvania law, if you have health coverage and the workers' compensation insurance company refuses to pay your medical bills, your health insurance company must do so. The health insurer may require proof that the workers' compensation insurance company refuses to pay your bills. This is ordinarily accomplished by sending to the health insurer a copy of a Notice of Workers' Compensation Denial, which you should get from the workers’ comp claims adjuster. Once this occurs, your doctors, hospitals and other medical providers may bill your health insurance company directly.
If you file a claim petition, the health insurance company (or a Union Health and Welfare Fund) may require the workers’ compensation insurance company to pay them back if you win your case. Keep a list of all payments made by your health insurance company, along with a list of all out-of-pocket payments you made.
What if they are only paying some of my bills?
Though you may have injured more than one body part in your work accident, insurance companies often list only one of the injured body parts on the Notice of Compensation Payable (NCP), which is supposed to contain a complete description of the injuries you suffered. This ordinarily is not a problem because insurers ordinarily will pay medical bills that are related to the work injury even if the condition is not listed on the NCP.
Sometimes conflicts occur over the description of the injury the insurance company has accepted. In general, the insurance company will try to describe the injury as narrowly as possible to keep them from running into difficulties later should some doctor they hire disagrees with your doctor about the nature of the injury. For example, if you suffer a herniated disc in your lumbar spine, the insurance company probably will describe the condition as a lumbar strain. If an insurance company doctor examines you later, the insurer does not want to be bound by an NCP that describes your injury as serious because it is easier to file a petition and prove you have recovered if they described your injury as minor.
There are situations in which their action in narrowly describing the injury can cause difficulties. If, for example, you suffered a knee injury in addition to your back injury, you will sometimes find that the insurance company refuses to pay bills for medical treatment for the knee. If the insurance company refuses to pay expenses associated with that condition, you have no choice but to file a petition to correct the NCP.
It is not uncommon, however, for people to develop conditions after a work injury has occurred that have nothing to do with the original work injury. If your knee starts bothering you 8 months after you injured your back, it is a virtual certainty that the insurance company will refuse to pay for any medical treatment for your knee. It is also unlikely you’ll be able to convince a judge that there is a relationship, unless you have a pretty good explanation by a reputable orthopedic surgeon.
If you receive medical treatment at the same time for work related and non-work related conditions, the insurance company must pay the bill, though they only are required to pay the amount set forth in the fee schedule for the work-related treatment. For example, if you go to an office visit and you are treated for your back injury and for an unrelated neck condition, the doctor will be entitled to payment from the workers’ compensation carrier for the office visit. Whether the provider is entitled to any additional payment from your health insurance carrier is a separate issue, but certainly the doctor is not legally permitted to double bill.
Keeping track of work-related medical bills
While your case is pending, you may pay medical expenses related to your injury, though many providers will accept a “letter of protection” from your lawyer and will not charge you in the meantime. If you pay cash for all or part of a medical bill, ask that the pharmacy, doctor or other medical provider to provide you with a receipt for the cash payment. If you pay by check, keep a copy of the canceled check.
If your claim has not been accepted, and you are pursuing a petition to obtain benefits, you should tell your medical providers to bill the insurance company anyhow. Even where a workers' compensation insurance company refuses to make payment of biweekly wage loss checks to you, they sometimes pay for your medical treatment. In many cases, they will agree to pay medical expenses, but not wage benefits, by issuing a “medical only” NCP.