PA Workers Comp Medical Treatment Bills and Fee Review

As attorneys who represent injured workers in PA, we are often told by our clients that their doctor or physical therapist is not being paid by the workers’ compensation insurance carrier. Moreover, the client is receiving bills from the provider, maybe even notices from a collection agency. This is a sticky area, since the rules are in place, but not easily enforceable.

The Pennsylvania Workers’ Compensation Act is very specific on this topic. Right in the Act, Section 306 (f.1)(7), it says:

“A provider shall not hold an employe liable for costs related to care or service rendered in connection with a compensable injury under this act. A provider shall not bill or otherwise attempt to recover from the employe the difference between the provider’s charge and the amount paid by the employer or the insurer.”

Well, that’s great! The provider can’t do what they are doing. Now what? This is where the problem lies. The legislature said what cannot be done, but neglected to put in anything that can be used to enforce this language. While a Penalty Petition can be filed against the employer or the workers’ compensation insurance carrier, one cannot be filed against the medical provider. Plus, considering the injured worker often needs the support and cooperation of the medical provider in litigation, antagonizing the medical provider is not usually in the best interests of the injured worker.

We try to educate the medical provider. We truly want the medical providers to be paid; they are providing a valuable service to our clients and deserve to be compensated. But, at the same time, we want any collections efforts against the injured worker to be stopped.

The proper way for a medical provider to bill for treatment related to a work injury in PA is for the provider to submit their bills on the proper forms (LIBC-9 and HCFA forms), and submit these with supporting documentation (like the office or treatment notes). The workers’ compensation insurance carrier then has 30 days to either pay the bill or submit the bill to Utilization Review (the tool available if they want to dispute whether the treatment is reasonable or necessary).

If the bill is not paid by the workers’ compensation insurance carrier in the proper time, or in the proper amount, the medical provider must file a form with the Bureau of Workers’ Compensation for “Fee Review” (LIBC-507). This is the step far too many medical providers ignore, by just jumping to the (unlawful) practice of billing the injured worker.

Once an administrative process issues a decision in the Fee Review, it can be appealed and heard before one of several Workers’ Compensation Judges (WCJ) who hear such actions. The medical provider need only file another form (LIBC-606) to have the process start. Our firm, among others, is perfectly willing to represent medical providers in these actions. What we are not willing to do, however, is have our clients pay the price for medical providers who are not following the proper procedures to be paid.