Healthcare Professionals

Treating the Injured Worker

The Pennsylvania Workers’ Compensation Act provides that the employer’s workers’ compensation carrier must provide payment for reasonable surgical and medical services rendered in connection with the treatment of a work injury.

The “90-Day” Rule

Most medical practitioners with any experience treating injured workers have probably been told that they will not be paid for treatment provided during the first 90 days after the work injury. But, this “rule” is not as cut and dried as injured workers and their doctors are often led to believe.

The Pennsylvania Workers’ Compensation Act, in Section 306 (f.1)(1)(i), does give employers a right to establish a list (or panel) of designated health care providers. When the list is properly posted and the necessary acknowledgment forms are signed, the employer should be responsible for payment only to those health care providers on the list during the first 90 days of treatment for the work injury. A closer reading of Section 306 (f.1)(1)(i) and relevant case law interpreting that section, however, makes it clear that the employer’s right to control medical treatment for 90 days is far from absolute.

Some key points:

  • Nothing in the Act prohibits the injured worker from treating with any doctor of his or her choosing at any time. The Act merely addresses the employer’s responsibility to pay for such treatment.
  • In order for the employer to limit the injured worker’s choice of medical providers, the employer must provide a clearly written notice to the injured worker of his or her rights and duties with regard to medical treatment. This notice must be signed by the employee a) at the time of hire, b) whenever changes are made in the list, and c) immediately following the work injury.
  • The list of employer-chosen health care providers must contain at least six providers. Three of the six providers must be physicians.
  • The listed providers must be reasonably geographically accessible to the injured worker.
  • The list of providers must contain a provider with specialties appropriate for the anticipated work-related medical problems of the employee. If a particular specialty is not on the list and the specialty care is reasonable and necessary for treatment of the work injury, the injured worker may treat with a health care provider of his or her choosing.

 

As a practical matter, very few employers in Pennsylvania will meet the above posting and acknowledgment requirements to compel an injured worker to treat with the employer’s 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 injured worker’s choice of medical providers during the first 90 days of treatment.

Submission of Medical Bills and Supporting Documentation to the Workers’ Compensation Carrier

Section 306 (f.1)(2) directs the medical provider to file periodic reports with the workers’ compensation carrier on a Medical Report Form. The Medical Report Form should be filed with the carrier within 10 days of commencing treatment and at least once a month thereafter as long as treatment continues.

Download a Medical Report Form

The medical provider, upon providing medical treatment to the injured worker, should forward its bill to the workers’ compensation carrier along with the CMS insurance claim form and the supporting medical documentation (office notes, operative reports, diagnostic test results, etc.).

It is important the medical providers are aware of what specific injury is recognized in a workers’ compensation claim and that the appropriate diagnostic code is used when submitting a bill to the workers’ compensation carrier.

Fee Review Procedure

Any dispute between the medical provider and the carrier regarding the amount and/or timeliness of the payment of a medical bill (including failure to pay interest) can be addressed by the provider filing an Application for Fee Review Pursuant to Section 306 (f.1). This Application can now be filed through the Department of Labor and Industry’s new Workers’ Compensation and Automation and Integration System (WCAIS) at http://www.portal.state.pa.us/portal/server.pt/community/wcais/20738 . 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.

Utilization Review

The workers’ compensation carrier has the right to file a Utilization Review Request in connection with any submitted bill 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 properly submitted bill.

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 injured worker’s treatment doctors. The URO will also contact the medical provider under review and discuss the contested treatment. Finally, the URO will accept and consider a written statement from the injured worker regarding the treatment and its effect on the injured worker’s relief and recovery.

The URO will make a determination solely as to whether the treatment in question is reasonable and necessary for the recognized work injury.

It is of utmost importance that the medical provider under review cooperate with the URO. If the provider fails to provide records to the URO, the URO must issue a determination that the treatment is not reasonable and necessary. Such a determination is not subject to review or appeal.

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