What follows is a guide on the basics of obtaining payment for medical bills in Pennsylvania workers’ compensation matters. Medical billing in workers’ compensation matters can be an unfamiliar and uncertain task. What is the process? What forms are to be used? What happens if payment is not timely or is denied? What are the time limits? Some common complaints are: workers’ compensation never pays on time, denies submissions, fails to pre-approve treatment, or just ignores the bill. Sometimes, it just seems easier to avoid dealing with workers’ compensation. However, this book is here to help you. Knowledge makes all the difference.
When a patient first presents to you stating they suffered a work injury, you must get some crucial information from them. Ask them for their employer’s name, address, and phone number. Next, ask for the workers’ compensation carrier’s name, address, and phone number. You will also need the claim number and the date of injury.
The patient should be asked to provide their Notice of Compensation Payable, Notice of Temporary Compensation Payable or a Workers’ Compensation Judge’s award recognizing the work injury. These documents will provide all of the above crucial information and, more importantly, confirm that the patient has an accepted workers’ compensation injury.
If the injury has been accepted, workers’ compensation pays for all reasonable, necessary and work-related medical treatment by “practitioners of the healing arts”. The Notice of Compensation Payable issued by the workers’ compensation insurance carrier describes the injury under the heading “Description of Injury” and “Body Parts” on the top left side of the form. Please keep in mind that workers’ compensation is only required to pay for treatment which falls within the “Description of Injury” and “Body Parts”. For example, if the injury is described as a cervical strain, workers’ compensation must pay for treatment to the neck. However, if the treatment being billed to workers’ compensation is to the right shoulder, workers’ compensation is not automatically responsible for payment. Some exceptions exist, such as when a test is performed to another body part to rule out causes for the work injury or pre-surgical testing. Knowledgeable counsel can help when such questions arise. Further, if the patient’s doctor feels that a condition not described on the Notice of Compensation Payable is work related, there are legal methods available to have the treatment paid for by workers’ compensation.
If the treatment or injury is denied as not work related, you may bill the patient’s private health insurance, Medicare or other government-sponsored health insurance. This is prudent for many reasons; most importantly, it protects the patient’s health and workers’ compensation claim by allowing them to continue treatment during denial by workers’ compensation. Besides lower reimbursement rates, drawbacks to billing sources other than workers’ compensation include:
- Unnecessary and costly co-pays to patient;
- Unnecessary and costly deductibles to patient; and
- Maximum private health insurance benefits attained prematurely, precluding further treatment for any condition over the patient’s lifetime.
If a medical bill is denied by workers’ compensation as not work related, a provider can then bill other insurance. The Commonwealth of Pennsylvania issued two (2) memorandums regarding the Insurance Department’s regulations governing the use of exclusions for workers’ compensation insurance in accident and health insurance (attached). These regulations require health insurance companies to pay claims if the workers’ compensation insurance company refuses coverage. If the health insurance company refuses to pay “because the treatment is work-related,” a letter enclosing these two (2) memos almost always causes quick payment. If private health insurance and/or government-sponsored insurance is billed during the course of litigation, in the event of a favorable Decision, workers’ compensation will be required to repay the private health insurance. Sometimes this is done by the workers’ compensation insurance carrier issuing a check directly to the private health insurance. The workers’ compensation insurance carrier can also make payments directly to the medical provider, who, in turn, will need to reimburse the patient’s private health insurance accordingly.
After the patient has been seen by the physician and a HCFA 1500 or UB has been created, you need to fill out an LIBC-9. Remember, this is a two-sided form even though you are only filling in one side. You must then mail the bill, LIBC-9, itemized bill, and medical records to the workers’ compensation carrier. There are no exceptions to this rule. An itemized statement or standard billing summary means nothing to the workers’ compensation insurance carrier! The itemized statement or billing summary are not sufficient requests for payment, and can legally be ignored. Compliance with the requirement that a completed LIBC-9 be sent with the bills is a prerequisite to the carriers’ obligation to process and pay the medical bill!
In Pennsylvania, workers’ compensation carriers have thirty (30) days (plus 6 days for mailing) to respond to a billing. If the response is late, compensation carriers have to pay 10% per annum interest. They can respond in the following manners:
- Denial (If denied as not work related, contact attorney);
- Filing a utilization review request; or
Fee Review (Amount of Payment)
If the carrier does not respond in the allotted amount of time or a payment amount is incorrect, you can then file a fee review. The Fee Schedule is on the Bureau of Workers’ Compensation Website at https://www.dli.state.pa.us. Fee Review is the procedure to review the amount of the payment. This can be due to improper downcoding. If the carrier does not strictly comply with the downcoding procedures mandated by Section 127.207 of the regulations, the provider is entitled to reimbursement for the actual charges. A Fee Review can also be used to challenge the timeliness of payment as can a penalty petition.
Fee reviews must be filed within ninety (90) days of the original bill date OR within thirty (30) days after a denial or disputed payment is received, whichever occurs later. These time limits are strictly enforced and any fee review filed late will be dismissed.
The Department of Labor and Industry, Healthcare Services Review Section governs these reviews. Only a medical provider can file a Fee Review. A tutorial is available at the Bureau of Workers’ Compensation website at www.dli.state.pa.us, Workers’ Compensation Medical Treatment Information, Healthcare Services Form Tutorials. FAQS are also available at www.dli.state.pa.us, Workers’ Compensation, FAQS, Healthcare Services Review FAQS. You may call the PA Workers’ Compensation Hotline at (717) 772-4447 to obtain a Fee Review form for filing.
It is important to remember that to file a fee review you must fill out a LIBC-507 (see above sample form) and send it with a copy of the original bill, itemized bill, LIBC-9 (with original bill date) and medical records. Include a summary of why you are filing the review. Send a copy of the packet to the compensation carrier and keep a copy for your records. The original gets mailed to the Bureau of Workers’ Compensation. They will notify you of a decision within thirty (30) days of receipt of all necessary documents. The party unsatisfied with the fee review determination may file an appeal by filing a Request For Hearing To Contest Fee Review Determination (see Form on next page). The appeal must be filed within thirty (30) days of the administrative determination and will be assigned to a hearing officer who will issue a decision within ninety (90) days of the close of the evidentiary record. Further appeal will now be assigned to a workers’ compensation judge.
Utilization Review (Reasonableness & Necessity)
If the workers’ compensation carrier has filed a Utilization Review (UR), you should check to be certain that the UR was filed within thirty (30) days of the workers’ compensation insurance carrier’s receipt of the medical bill(s) being requested for review. It can be argued that the failure of the carrier to timely challenge a bill waives their right to challenge the reasonableness and necessity of the treatment.
When requested by the assigned utilization review organization (URO), you must do the following:
- Timely provide your records to the URO!;
- Insist on a telephone conference with the UR’er;
- Encourage the patient to continue reasonable treatment; and
- Encourage the patient to provide a written statement to the UR’er when requested.
When the medical provider is requested to provide medical records to the URO, the URO shall provide reimbursement to the medical provider for copying costs at the rate specified by Medicare, along with payment for actual postage costs. Also, reproduction of radiographic films (x-rays, MRI’s, CT Scans, etc.) shall be reimbursed at the usual and customary charge. (See Section 127.463(a) and (b) of the Rules and Regulations governing actions under the Pennsylvania Workers’ Compensation Act)
If the UR determines that the treatment was unreasonable and/or unnecessary, contact the Attorney to file an appeal of the UR determination.
The appeal will be a brand “new” review of the treatment by a Workers’ Compensation Judge. Also, most importantly, the workers’ compensation insurance carrier will now have the BURDEN to prove that the treatment was unreasonable and unnecessary. The petition to review the UR determination will be assigned to a workers’ compensation judge and will not be binding on the judge.
How long does the UR process take? When a UR request if filed, it takes about five (5) days for the Bureau to assign the petition to a URO. The URO will then collect the medical records and is prohibited from giving opinions on causation. A request for UR shall be deemed compete upon receipt of the medical records from the provider, or thirty (35) days after the notice of assignment of the review to a URO, whichever comes first. The provider will be given thirty (30) days to provide the records. Failure of the medical provider to timely provide records will cause the treatment to be denied as not reasonable and necessary! Filing an appeal will not help. Once deemed completed, the URO has thirty (30) days to render their decision.
If a provider, an employee or an employer disagrees with the UR determination, they can file a request for review of the UR determination. The medical provider is not dependant on the injured worker filing an appeal.
The medical provider has standing to file the appeal.
We represent many treating doctors who hire us directly to file the appeal and to get their bills paid after a negative UR determination is issued.
Step 3 Silence
In the event that you receive NO RESPONSE to your original submission of your bill(s) to the workers’ compensation insurance carrier or receive some excuse like “the check is in the mail,” then you should immediately contact the Attorney, who will review the matter to determine which of the following petitions should be filed:
- File Prospective UR: a quick and effective method of obtaining pre approval to guarantee payment of medical bills before the treatment is even rendered (don’t believe the myth that there is no such thing as pre-approval in PA workers’ comp);
- File Review Petition for the payment of medical bills and an additional 10% interest on the unpaid bills;
- File Penalty Petition requesting the additional payment of up to 50% penalties for the carrier’s violation of the PA Workers’ Compensation Act by delaying payment of medical bills.
A review petition is needed when the treatment is for a condition not clearly related to the injury accepted in the Notice of Compensation Payable. A Penalty Petition can be filed when payment is not made within thirty (30) days, or if payment is received well past the 30-day time frame. A Penalty Petition is most often used when workers’ compensation ignores medical bills which are properly submitted and clearly related to the work injury. When filing a Penalty Petition, the medical bill must be clearly work-related, i.e., the medical documentation that was submitted with the bill clearly identifies treatment to the injury/body part described on the Notice of Compensation Payable or Judge’s Award.
Often times the mere filing of the Penalty Petition will be enough to effectuate payment from the workers’ compensation insurance carrier. If not, a Judge will issue a Decision as to whether the workers’ compensation insurance carrier failed to make timely payment and, if so, order payment to be made. The Judge can also order penalties to be paid by the workers’ compensation insurance carrier, up to 50% of the outstanding medical bills plus 10% interest.
Lastly, if a bill is denied because it was within the first ninety (90) days of treatment and the doctor is not on the company posted list, call us to see if any of the many exceptions apply. Usually, one does and the compensation carrier must pay the bill. It is a myth that injured workers cannot treat with a doctor of their own choice during the first ninety days.
Payment of medical bills under the Pennsylvania Workers’ Compensation system can be confusing and complicated. It is the desire of the attorneys at Calhoon and Kaminsky P.C., that this guide book, the flow chart and the sample forms contained herein will assist you in an organized and simplified fashion to collect your medical bills in an almost hassle free fashion. However, hassles are bound to occur. When they do, feel free to contact the attorneys at Calhoon and Kaminsky P.C., to assist you with this process and achieve the ultimate goal of providing medical care to your patients and getting your Bills Paid.
No part of this blog may be copied or reproduced in any manner whatsoever without the express written consent of Calhoon and Kaminsky P.C. Comments in this blog are not intended to provide legal advice. This is a guide. For specific legal advice on your case, you should call a reputable and Board Certified workers’ compensation lawyer. It should never cost you any money to consult with such a lawyer. We can be reached 24 hours a day at 1-877-291-9675 or by emailing email@example.com.