Having Problems Getting Medical Care For A Work Injury?
Physicians, hospitals and other licensed health care providers in Pennsylvania should provide treatment for work-related injuries regardless of whether the injured worker has health insurance. In practice, however, many medical providers will require secondary insurance, may insist on getting pre-approval from the workers’ comp insurance carrier (no such pre-approval process exists), or may refuse to accept a client with a work injury bringing a workers’ compensation claim.
Our Firm Can Help You Get The Care You Need
The workers’ comp attorneys at Wolf, Baldwin & Associates, P.C. — who are certified specialists in workers’ compensation law by the Pennsylvania Bar Association — understand Pennsylvania’s claims system. We have worked with injured workers and with area medical providers for many years. We know which doctors will treat injured workers and can help steer you in the right direction to get the medical treatment you need.
How The Workers’ Comp System Is Supposed To Work
When the system works as it should, the injured worker gives notice of a claim for workers’ compensation benefits and that claim is accepted. From that time forward, the injured worker never has to make a co-payment or pay any other fee for medical care associated with an on-the-job injury or illness.
The healthcare provider who has treated the injured worker submits bills on the proper forms to the workers’ compensation insurance carrier. The insurance carrier then has 30 days to accept or deny the bill. If the medical services rendered were reasonable, necessary and related to treatment of the work injury or illness, the bill should then be paid. Payment will be made based upon a fee schedule for workers’ comp that changes annually.
As a service to medical professionals and to our clients who treat with those professionals, we offer seminars regarding the processes and procedures of medical billing under the PA Workers’ Comp Act.
Common Problems In The Pennsylvania Workers’ Comp System
What can actually happen is that the workers’ comp insurance carrier fails to take any action within the 30-day period. The company neither accepts nor denies the bill. When the medical provider receives no payment and no response, he or she may refuse further treatment unless the patient agrees to pay the bills.
Being denied medical care is clearly wrong.
Our attorneys negotiate with doctors and healthcare providers so that they continue to provide treatment while also taking legal action, if necessary, to force insurance carriers to act appropriately. We can file a penalty petition with the Bureau of Workers’ Compensation, seeking to prove that the insurance carrier has unlawfully delayed payment.
Insurance Carrier Denials
The insurance carrier may deny the medical bill within the 30-day period, but can do so for only two reasons: because it is unreasonable or unnecessary, or because it is not related to the workplace injury.
If the insurance carrier does challenge reasonableness or necessity of the medical treatment provided, it must do so within 30 days using the Utilization Review procedure of the Pennsylvania Workers’ Compensation Act. The Bureau assigns a Utilization Review Provider who reviews the medical records, speaks with the doctor whose bill is in question and asks the injured worker for a written statement. The reviewer then issues a determination regarding whether the bills are reasonable and necessary. If so, the workers’ comp insurance carrier can appeal, but it must pay the bills. If the bills are rejected, the injured worker can file an appeal.
Talk To Our Experienced Lawyers About Your Workers’ Comp Issues
Offices in Pottstown, West Chester, Reading and Pennsburg, Pennsylvania, serving communities such as Coatesville, Douglassville, Hereford, Kutztown, West Caln Township and West Vincent Township
Insurance companies will always be represented by attorneys who are experienced in Pennsylvania workers’ comp law. If you suffered injuries in a workplace accident, you need and deserve legal representation as well. At Wolf, Baldwin & Associates, P.C., we represent injured workers throughout southeastern Pennsylvania. For a free consultation, contact a denied benefits lawyer.
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