medical practitioners guide

8/6/2019 Medical Practitioners Guide

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The Workers Compensation and

Social Security Disability Firm

215-568-7500

A Medical Practitioners Guide to

Pennsylvania Workers Compensation

Pond, Lehocky, Stern & Giordano

30 South 17th

St, 17th

Floor

Philadelphia, PA 19103

Pondlehocky.com


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The law firm of Pond Lehocky Stern Giordano is committed to ensuring that ourclients receive the appropriate medical treatment to which they are entitled, and thattheir treating doctors are properly compensated in a prompt manner by the workerscompensation insurance carriers.

This booklet is designed to provide an overview of the workers compensationclaimants right to medical treatment, and to advise medical practitioners of their rightsand reporting requirements with regard to treatment and billing in connection with aworkers compensation claim.

We appreciate the service that you provide our clients. If you have any questionsbeyond the scope of this booklet, you are encouraged to contact Pond Lehocky SternGiordano so that we can assist you.


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The Injured Workers Right to Medical Treatment

The Pa. Workers Compensation Act, in Section 306 (f.1)(1)(i), provides that the workers compensationinsurance carrier shall provide payment for reasonable surgical and medical services rendered in connection

with the treatment of a work injury.

Submission of Medical Bills and Documentation to Workers Compensation Carrier

Section 306 (f.1) (2) provides that any medical provider who treats an injured worker must file periodic reports

with the workers compensation carrier on a Medical Report Form (a copy of the Medical Report Form isincluded in this Guide). The Medical Report Form must be filed within 10 days of commencing treatment and at

least once a month thereafter as long as treatment continues.

The medical provider, upon providing medical treatment to the injured worker, should forward its bill to the

workers compensation carrier along with a CMS (formerly HCFA~ insurance claim form arid the supporting

medical documentation (office notes, operative reports, diagnostic test results, etc.). A blank CMS claim form isincluded in this Guide.

Payment Medical Bills by the Workers Compensation Insurance Carrier

The workers compensation carrier is required to make payment within 30 days of receipt of the bill and

supporting medical documentation from the medical provider.

Pursuant to the Act and its medical cost containment regulations, the reimbursement rates for medical bills on a

workers compensation claim are calculated from a base Medicare-associated rate and subsequent annuaincreases as determined by the Pa. Bureau of Labor and Industry. If a Medicare reimbursement rate does notexist for the service in question, payment shall be at 80% of the amount most often charged for the service by

similar medical providers in that geographic area.

Fee Review Procedure

If the medical provider wishes to dispute the amount and/or timeliness of the payment of medical expenses, theprovider must file an Application for Fee Review Pursuant to Section 306 (f. 1). The Application must be filed

no more than 30 days following notification of a disputed treatment or 90 days following the original billing

date of the treatment which is the subject of the dispute, whichever is later.


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Carriers Right to Review, Deny and Challenge Payment of Medical Bills

Until the injured workers claim is either voluntarily accepted by the carrier or is grat~tedby the Workers

Compensation Judge, the carrier is under no obligation to approve, contest, Or pay for any medical treatment

received by the injured worker. A medical provider giving treatment to an injured worker with a pending claimmust wait until resolution of that claim to seek payment. The medical provider is advised, however, to send the

bill and records to the carrier while the claim itself is being contested.

Utilization Review (Treatment Denied as Unreasonable and/or Unnecessary)

On an open (accepted) workers compensation claim, the carrier may file a Utilization Review Request

in connection with any bill that is forwarded. The Utilization Review procedure is used to contest the

reasonableness and/or necessity of the treatment in question.

The Utilization Review Request must be filed by the carrier within 30 days of receipt of a properlysubmitted bill with supporting medical documentation. The Utilization Review Request will be

forwarded by the Bureau to a Utilization Review Organization (URO). The URO will request and

review medical records from the workers treating doctors. The URO will also accept a writtenstatement from the injured worker. The URO will make a determination solely as to whether the

rendered treatment is reasonable and necessary for the recognized work injury. Any party(the doctor, the

injured worker, the insurance carrier) has a right to appeal the determination to a Workers

Compensation Judge by filing a Petition to Review Utilization Review Determination. Note that if the

medical provider being reviewed fails to provide records to the URO, the URO must issue a

determination that the treatment is not reasonable and necessary and, furthermore, such

determinations :maynot be reviewed by a workers compensation judge.

Treatment Denied as Unrelated

In addition to challenging payment for treatment as unreasonable or unnecessary, the carrier may denypayment by alleging that the treatment is not relatedto the work injury. In such instances, the medica

provider should consult with a workers compensation attorney regarding the appropriate course of

action, which is usually a Petition for Penalties or a Petition to Review Compensation Benefits toexpand the description of the work injury.

It has been long understood that the workers compensation insurance carrier was under no obligation to pre-approve any medical treatment. That is, medical providers have had to render treatment and then submit their

bill without knowing if the carrier will contest the bill or pay it. However a couple of recent Commonwealth

Court cases, McLaughlin v. WCAB (St. Francis House), 808 A. 2d 285 (PA Cmnwlth 2002) and Brenner vsWCAB (Drexel Industries), 856 A. 2d 213 (PA Cmwlth. 2004), have apparently placed some burden on the

carrier to either formally contest or pre-approve treatment for the recognized work injury. It is not yet clear onwhat practical effect these decisions will have or how the workers compensation judge will interpret them.


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The Employer/Carriers Limited Right to Control the Injured Workers Medical Treatment

The Pennsylvania Workers Compensation Act gives employers the right to establish a list of designated health

care providers. When the list is properly posted and proper acknowledgment forms are signed, injured workers

must seek treatment for the work injury or illness with one of the employers designated providers for 90 daysfrom the date of the first medical treatment. There are some specific guidelines provided in the Act for these

lists, including:

1. The employer must provide a clearly written notice to employee of the employees rights andduties.

2. The notice must be signed by the employee a) at the time of hire, b) whenever changes are madein the list, and c) at the time of injury.3. The list must contain at least six providers; three of the six providers must be physicians.4. Listed providers must be geographically accessible.5. Listed providers must contain specialties appropriate for the anticipated work-related medicalproblems of the employee.

6. If a particular specialty is not on the list and the specialty care is reasonable and necessary for

treatment of the work injury, the employee will be allowed to treat with a health care provider of hisor her choosing.

At the end of the 90-day period - or when the claimant is discharged from care by the panel doctor -the claimant

can treat with a doctor of his/her own choosing.

In practice very few employers in Pennsylvania will meet the above posting and acknowledgemenrequirements to compel an injured worker to treat with the employers panel doctor for the first 90 days of

treatment. The Pennsylvania Commonwealth Court, in Pennsylvania Department of Corrections v. WCAB

(Kirchner), 805 A.2d 633 (Pa. Cmwlth. 2002), clearly detailed the strict requirements that the employer must

meet in order to maintain control over the employ choice of medical providers during the first 90 days oftreatment.


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Payment of Medical Bills Through the Workers Private Health Insurance

Frequently, an injured worker whose claim is not accepted will seek to use his private health insurance until theclaim is accepted. Many private health insurers have balked at paying for medical services that are allegedly

related to a work injury. The Department of Labor and Industry, in a memo from the Director of the Bureau of

Workers Compensation, has made it clear that the private health insurers must pay for such treatment if theclaim is not currently accepted or granted. A copy of the Bureaus memo is included in this Guide.

In a related matter, the Commonwealth Court has ruled that when a private health insurer pays for medical bills

and the workers compensation claim is subsequently accepted or granted, the workers compensation carriermust reimburse the private health insurer at the exact rate the private health insurer paid the medical provider

(not merely the reimbursement schedule rate). [See Furnival State Machinery/Transamerica Insurance Group v

WCAB (Slye) and Villanova University v. WCAB (Mantle).]

Payment of Interest on Medical Bills

Interest is payable on medical expenses.

The Pa. Bureau of Workers Compensation, in its Fall 2004 newsletter, issued an advisory to workerscompensation carriers that interest must be paid on medical bill payments when payment is made after theinquired 30-day time frame. The Bureau cautioned that failure by the carrier to pay interest may subject them to

penalties and referral to the Insurance Department for further action.

A Utilization Review Organization has authority to order the carrier to pay interest to the provider on

reasonable and necessary outstanding bills.

Medical Billing Codes

It is important that the medical practitioner be aware of what specific injury is recognized on a workers

compensation claim and that the appropriate diagnosis codes are used when submitting bills to the insurancecarrier.


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WORKERS COMPENSATION SETTLEMENTS - MEDICARE APPROVAL

If a claimant is eligible for Medicare benefits at the time of settlement (or if the claimant expects to be eligible

within 30 months of settlement), that claimant is required to obtain Medicare approval in order to move forward

with the settlement. Centers for Medicare Services (CMS) is concerned about having liability for claimantsmedical bills related to the work injury transferred to Medicare after the Workers~ compensation case is settled

and, therefore, CMS may require a Medicare Set Aside Trust. Claimant must submit medical documentation

including narrative reports from his/her doctors, indicating any anticipated future treatment for the work injury

and its associated costs. CMS will consider this information to determine what portion of the settlement moneymust be placed in a Set Aside Trust. The claimant must then pay for any medical bills incurred after the date of

settlement with the funds in the Medicare Set Aside Trust. Once the Set Aside Trust is exhausted, then

Medicare will become responsible for bills for the work injury.

Frequently, claimants attorney will contact the claimants treating doctor regarding creating a lifetime care plan

for the patient to be presented to CMS. This lifetime care plan is critical in helping CMS determine the amountnecessary for a Set Aside Trust and ensuring that the Claimants interests are protected and that future medical

bills are paid. The prompt cooperation of claimants treating doctor is essential in helping the claimant move

forward with the resolution of his or her claim.


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CMS Form


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Bureau Memo Regarding Coverage Disputes Between WC Carriers

and Private Health Insurers


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Notice of Compensation Payable


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Notice of Workers Compensation Denial


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Application for Fee Review


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