When your workers’ compensation claim is accepted in Pennsylvania, you are entitled to wage loss benefits, as well as reasonable, necessary, and related medical expenses. These medical expenses are paid by your employer’s workers’ compensation carrier…..but not until they are closely reviewed by the workers’ compensation adjustor. If your employer has a list of Panel Providers, which by law, they should have, then within the first ninety (90) days after your work injury, you must treat with a provider or providers on that list, in order for your medical bills to be paid by the workers’ compensation carrier. Along with this rule is that the list should be given to you at the beginning of your employment and also at the time that you give notice of the work injury. If your employer does not have panel providers, then you are free to treat with whomever you want for the work injury.
When you do have medical expenses as a result of your work injury, the adjustor has thirty (30) days from receipt of the bill to either pay it, deny it as not related to the work injury, or challenge the bill as being not necessary and reasonable treatment, through a process known as a Utilization Review. You should also be aware that when the carrier pays the bills, they are paid at a re-priced dollar amount, rather than paying the entire bill sent by the medical provider.
With the Utilization Review, the bills and other relevant medical records and forms are sent to a like medical provider to offer their opinion as to whether the care rendered to you is reasonable and/or necessary as it relates to the work injury. A very common example of this is chiropractic treatment. Let’s say you go to a chiropractor, and he or she wants you to treat three times a week for a period of months…. when the adjustor gets all of these bills, they would send them to another chiropractor to review and comment on the reasonableness and necessity of the treatment. The whole purpose of this Utilization Review process is to save the insurance company money by not paying bills. To further complicate things, there can be a prospective Utilization Review regarding all future treatment, or the more typical is the Utilization Review done on treatment that has already taken place and been billed for.
If you receive notices that your bills have not been paid for your work injury, please make sure that you advise your lawyer, so that the proper actions can be taken. It may be that a Penalty Petition needs to be filed, if bills are not paid and no Utilization Review is filed. For any questions, always feel free to contact Paula Robinson at Robinson Law, LLC
