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The PA Workers’ Compensation Insurance Company won’t return my phone calls about approving my surgery?

The PA Workers’ Compensation Insurance Company won’t return my phone calls about approving my surgery.  What can I do?

The short answer is that THEY DON’T HAVE TO. Under a wrinkle in the PA Workers’ Compensation Insurance law, Workers’ Compensation insurance companies don’t have to accept or reject a proposed surgery until the procedure has been completed. This creates a “Catch-22” for the injured worker because the doctor may not want to do the surgery until there is reasonable assurance of payment.

So, what do you do? Here are the steps:

  1. Look at the “Description of Injury” contained on the Notice of Compensation Payable (NCP) ( or, in some cases, a Supplemental Agreement or WC Judge’s Order). The NCP is a very important document  because it not only shows that a WC case is officially accepted and open; it also shows what medical bills the Workers’ Compensation insurance company is required to pay.
  2. Check and see if the proposed surgery is for that same body part described in the Notice of Compensation Payable. If it is, the Workers’ Compensation insurance company will have to pay the bill. If not, they won’t pay and the injured worker will have to file a Petition to Review the Notice of Compensation Payable.
  3. Orthopedic surgeons usually have a staff person who is knowledgeable about PA Workers’ Compensation reimbursement issues and can help you if you give them the Notice of Compensation Payable.
  4. You can seek pre-approval through Utilization Review which asks the Bureau of WC to appoint a doctor  to review your case and decide whether a proposed surgery or other treatment is reasonable and necessary.
  5. You can submit the proposed surgery through other non-WC insurance after the WC insurance issues a denial, then seek to have them reimbursed. Be careful, the other carrier might ask you to fill out a form asking you to check a yes/no box on whether the proposed surgery is work related. Don’t check either box; just write in “ WC denied”
  6. You can also ask the doctor to perform a relatively inexpensive pre-surgical procedure. Then, submit that bill to the WC Carrier. If it is refused, then file a Petition for Penalties to get the whole matter in front of a Workers’ Compensation Judge.
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