Navigating the Maze of Medical Reimbursement for Pennsylvania Work Injuries: What every Claimant, and Doctor, Ought to Know

Introduction
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\nThe changes enacted in Workers' Compensation by the Pennsylvania legislature in 1994 and 1996, coupled with various Court decisions since then, have produced a sometimes confusing minefield of rules and regulations regarding reimbursement of medical bills for work related injuries. Below is a summary of some of the important highlights of the Workers' Compensation Act as it pertains to medical bills and the effects of the most recent changes.
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\nThe Accepted Injury: The Most Important Question You Should Ask
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\nWork injuries are recognized either by a Notice of Compensation Payable, Temporary Notice of Compensation Payable, Agreement for Compensation or a decision of a Workers' Compensation Judge. It is important for any medical provider to ascertain the exact nature of the injury recognized as it controls what medical treatment will be paid. Such decisions are often the decision of an insurance adjuster or clerk with no medical training. Be sure to insist on a copy of the document acknowledging your injury so you can immediately determine if all of your work injuries have been cited. If not, request your employer or their insurance carrier to change the recognized injury or consult an attorney right away.
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\nEmployers in Pennsylvania are required to pay for reasonable and necessary medical expenses related to the work injury. Medical benefits under section 306(f)(1) of the Act are payable even if there is no lost time from work. There is no waiting period for payment of medical expenses, unlike payment of wage loss benefits. Although the employer can refuse to pay medical expenses if they are not causally related to the recognized work injury, the employer asumes the risk of attorney's fees and penalties if the expenses are later found to be causally realted and not under Utilization Review, which is discussed later in this article.
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\nWhere a claimant suffers from an admittedly compensation disability, the burden of proof remains with the employer to establish that medical services are not reasonable or necessary. Treatment is reasonable or necessary even if it is merely palliative, is designed only to manage symptoms rather than cure or permanently improve the condition or is only for pain relief. Note, however, that voluntary payment of medical bills is not an admission of liability on the part of the employer.
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\nPanel Physicians: Do You Have to Treat with Them?
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\nClaimants are required to treat with a medical provider on the employer's list of designated physicians for 90 days from the date of first treatment. But the employer must provide written notice to the employee that treatment with the panel physician is required. The regulations require that a list of designated healthcare providers must be posted in the workplace, and there are restrictions on who may be listed as a designated provider. For instance, if the employer utilizes a Coordinated Care Provider for these services, they cannot control all six spots on the list. Furthermore, the employer is required to provide written notice to the employee that treatment with a panel physician is required and to obtain written acknowledgement of that notification both at the time of hire and immediately after the accident or as soon as possible under the circumstances of the injury.
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\nDid Your Doctor Send in the Correct Forms for Payment?
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\nWhen a claim is accepted, the employer is required to make payment within 30 days of the receipt of bills and records from the provider unless a Utilization Review has been initiated by the employer/insurer. A provider is not permitted to hold the employee liable for medical expenses incurred for treatment for a work injury nor may the provider bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer/insurer.
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\nRequests for payment of medical bills must be made either on HFCA Form 1500 or UB92 Form (HFCA Form 1450). Until submitted, insurers are not required to pay for the treatment billed. The Act also requires that providers submit periodic medical reports with the employer on the prescribed Bureau Form LIBC-9. Failure to do so relieves the employer of responsibility to pay the bills. These forms and many others can be obtained on the Bureau of Workers' Compensation website at www.dli.state.pa.us.
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\nPetitions for Fee Review: How You and Your Doctor Can Proactively Protect Your Payments.
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\nThe process of reviewing the amount and/or timeliness of the payment of medical expenses is found in section 306(f)(1)(5) of the Act. This section grants providers the right to file an application with the Bureau for review of the amount and/or timeliness of an employer's payment of their bills within 30 days following notification of disputes concerning their bills or 90 days following the original bill dates. If denied, the provider can still resubmit the bill and the required reports to the employer, and if denied again, the provider still has 30 days following notification of the denial to seek review of the fee dispute. The fee review process presupooses that liability for the work injury has been established and cannot be used to determine compensibility of the work injury and resulting treatment.
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\nThe Act further provides that payment shall be no more than 113 percent of the applicable Medicare reimbursement mechanism, or if none exists for treatment, 80 percent of the amount most often charged by similar providers in the geographic area.
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\nUtilization Review (URO): Challenging the Need for Ongoing Treatment
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\nThe employer can request review of a medical bill prospectively, concurrently or retrospectively by filing an application for utilization review so long as it is filed within 30 days of receipt of the medical bill in question. The Utilization Review Organization has the burden to make reasonable efforts to obtain all of the medical records regarding the treatment in question unless the treatment physician fails to supply the records within 30 days. Failure to provide the records will also preclude the provider the right to appeal an adverse decision. However, assuming records were properly provided, if either party disagrees with the URO findings, the party may file a Petition to Review within 30 days of the receipt of the URO decision.
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\nPetitions to Terminate: The Ultimate Weapon to Stop Medical Reimbursement.
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\nAfter the employer obtains a medical report, either from a treating doctor or one selected to examine the claimant, which finds that claimant has fully recovered from the work injury, the employer may file a Petition to Terminate Compensation. This petition has the potential impact of stopping both medical and wage loss benefits. Claimants are best advised to immediately contact an attorney at this time to defend these actions if they continue to be disabled from the work injury, even if they have returned to work and even if they are earning wages equal to or greater than the pre-injury wages. Failure to defend these actions can forever bar future payment of work related medical bills. Typically these cases are assigned to a Workers' Compensation Judge in the County where claimant resides and both sides are permitted to present evidence. An initial hearing allows the defendant to seek the temporary stopping of compensation and medical bills; however, since is rarely granted if properly defended by an experienced claimant's attorney.
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\nPetition for Review: Adding Injuries Not Originally Recognized
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\nIf an employee receives treatment for new symptoms that allegedly arise from a work related injury and the employer refuses to pay the associated medical bills then (1) when the causal connection is not obvious the burden is on the employee to establish the connection through medical testimony and (2) if the causal connection is obvious, the burden is on the employer to prove they are not related.

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