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Doctors Can Not "Balance Bill" Workers' Compensation Claimants

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Yesterday I received a call from a workers’ compensation client that had received a bill from one of his medical providers.  Essentially, what this provider was doing was “balance billing” its patient.  The client called to ask me a rather simple question that many workers compensation claimants often wonder about:  “Are my doctors allowed to bill me for the amount that workers compensation insurance doesn’t cover for medical costs?”  The answer is a resounding “No!”

Under the Pennsylvania Workers Compensation Act, a medical provider is not permitted to hold the injured worker liable for medical expenses incurred for treatment of a work-related injury;  nor may the medical provider bill or attempt to recoup from the injured worker the difference between the medical provider’s charge and the amount paid by the employer or insurer.

In fact, Act 44 provides cost containment limitations that make the attempt to collect such payments, or “balance bill” the injured worker illegal.  The proper procedure, if a medical provider wants to dispute the amount paid by an employer or insurer, is to file a fee review application.

Whenever a claim is accepted, the employer or insurer is to make payment of medical expenses within 30 days of the receipt of bills and records from the healthcare provider, unless the employer or insurer disputes the reasonableness or necessity of the treatment by filing a utilization review.

In one recent case, we were representing a client where the defendant was refusing to pay for a shoulder replacement, not based on a lack of reasonableness or necessity, but where they were challenging causation.  It is important to note that an employer may deny payment of medical expenses without first filing a petition with the WCJ, if the treatment is not causally related to the work injury.  The defendant in such a case may run the risk of a significant penalty however.

Unless such a challenge is successful, the employer or insurer will be responsible for the Act 44 amounts and the medical provider who accepts workers compensation will be bound to accept that amount and no additional payment from the injured worker.  I informed my client I would be happy to write a letter to his provider pointing out this practice was illegal; but he said he would mention it to them first and see what happened.  I was amused when he called me later in the day to let me know the office was “sorry” for this “mix up.”


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