A fee review in a Pennsylvania workers’ compensation case is a process where a healthcare provider can dispute the amount or timeliness of a payment made by a workers’ compensation insurer or employer for medical services rendered to an injured worker.
Here are the key points about the fee review process:
- Purpose: The fee review process ensures that healthcare providers are paid appropriately and timely for the medical services they provide to injured workers.
- Initiation: A healthcare provider can request a fee review if they believe that the payment for their services was incorrect, either in terms of amount or timing. This can include disputes over the application of the medical fee schedule or payment delays.
What the Injured Worker Can Do to Help Get Their Bills Paid
If you are injured on the job, there are a few things you can do to help make sure that your treatment expenses are properly submitted by your healthcare provider and paid for by the insurance carrier. At the very least, you should know the name and contact information of the workers’ compensation insurance carrier and provide that to your healthcare provider. The insurance carrier is also required to issue some type of document within 21 days of your injury either accepting or denying your claim.
If your claim is denied, the procedures for billing under workers’ compensation benefits will not apply until you establish that you have sustained a work injury. If your claim is accepted, you should receive some type of document, usually either a Notice of Temporary Compensation Payable or a Notice of Compensation Payable. You should provide a copy of this to your healthcare provider, as it will include all of the necessary contact information to process your medical bills appropriately.
What the Healthcare Provider Should Know And Do: Initial Billing Procedures For the Healthcare Provider
Gather Information
Ask your patient the date of injury, the name and address of the workers’ compensation insurance carrier, the claim number, and contact information for the claims representative. It would be best if your patient could provide you with the document issued by the insurance carrier accepting responsibility for the injury, i.e. a Notice of Compensation Payable or Temporary Notice of Compensation Payable. Pay particular attention to the nature of the injury that has been accepted. Insurance carriers often understate the severity of the injury.
Submit your Bill
Bills should be submitted to the insurance carrier on either the HCFA form 1500 or the UB 92 (HCFA form 1450) ALONG WITH a Medical Report on form LIBC-9. You must submit your bills using these forms to preserve your right to payment. The forms can be found, free of charge, through the Workers’ Compensation Bureau website. Questions about the forms may be submitted via a WCAIS Customer Service Request, or you may contact them directly by calling 844-237-6316 or by email.
Fee Review FAQs
How much can you expect to be paid?
The Pennsylvania Workers’ Compensation Act, Medical Cost Containment provisions indicate that medical fees are 113% of the Medicare reimbursement applicable for comparable services rendered. These rates are adjusted annually by the percentage change in the statewide average weekly wage. Other fee schedule adjustments may also be made to recognize Medicare code changes and geographic provisions. If no Medicare payment mechanism exists for a particular treatment, product, or service, the payment amount is 80 percent of either the usual and customary charge in the geographic area where rendered or the actual charge, whichever is lower.
When will you be paid?
Payment should be received within 36 days of the date you submitted your bill. (30 days for processing plus 3 days for mailing on each end).
What to do if you don’t get paid?
If you receive a Denial of your bill, or if you receive no response within 36 days, the medical provider MUST file a Fee Review with the Bureau of Workers’ Compensation.
The forms to file Fee Review can be found on the Department of Labor & Industry website.
There are very strict time limitations to do this, and waiting for or requesting reconsideration from the insurance carrier will not extend these deadlines. Fee Review must be filed within 30 days of the date you receive a denial, or within 90 days where no response is received. More information about Fee Review can be found below.
You should be aware that if you do not follow the billing guidelines established by the Workers’ Compensation Act, you may never receive payment for your services. Under the Workers’ Compensation Act, an injured worker is not responsible for the payment of medical treatment that is reasonable, necessary, and related to a work injury. Therefore, you cannot expect to collect payment from the injured worker. However, if you follow the proper procedures under the law, payment will likely be received.
Filing the Application for Fee Review
The Bureau of Workers’ Compensation has an online system for submission of the electronic version of the Application for Fee Review. WCAIS stands for Workers’ Compensation Automation and Integration System. You may also file paper versions via mail, but this method is discouraged and could lead to long delays in processing your application. You can register to use the WCAIS system.
Time Limits For Filing An Application For Fee Review
- Do not file until at least 36 days have passed since you first sent the bill to the insurance carrier, or the employer if they are self-insured.
- The application must be filed within 30 days following notification of a denial or 90 days from the original date of billing, whichever is later.
How To Get The Necessary Forms
Click here to find the forms to file Fee Review.
How to know whether to file for amount, timeliness, or both?
- If you have been paid correctly, but your payment was received late, check the TIMELINESS box.
- If your bill was not paid in accordance with the workers’ compensation medical fee schedule, check the AMOUNT box.
- If your payment is late and you disagree with the payment, check the BOTH box.
- If you were not paid at all, you may file for timeliness, amount, or both.
How to know whether a payment is timely?
If you have not received payment from the correct party within 36 days of the date you properly billed the insurer, payment may be untimely. (30 days + 6 days’ mail time = 36 days).
What must be included with an application for fee review?
It is your responsibility to provide a copy of any and all documentation you sent to the insurer for the treatment you are requesting to be reviewed, which at a minimum should include:
- The completed LIBC-9, Medical Report Form that was forwarded to the insurer or self-insured employer. Without evidence of an LIBC-9, the fee review application may be considered incomplete.
- Copies of all original bills pertaining to the date(s) of service. The date on the bill is important for the purposes of fee review. Make sure the date on the copy used for fee review has the same date as the original bill sent to the payer.
- Office notes, etc., supporting documentation of services rendered.
- Properly coded bills on UB-04 or CMS forms. If submitting a UB-04, provide a copy of the itemized bill or statement as submitted to insurer, including associated charges to the respective revenue codes.
- Explanation of Review (EOR) or denial, which must coincide with dates of service.
How To Avoid Having The Application Rejected
The Workers’ Compensation Automation and Integration System (WCAIS) prevents most technical filing errors through its online filing process.
- Make sure the fee review only contains information for one injured worker and one provider.
- Make sure to redact information relating to other workers from EOBs submitted with the application.
- Make sure at least 36 days have passed from the date the insurer was billed prior to filing.
- Ensure all required documents are submitted and accurately reflect the original billing submission to the insurer, including the bill date on the bill form and the report date on the LIBC-9.
- Under Section 306(f.1)(5) of the Workers’ Compensation Act, an application for Fee Review will be returned and your request for review may not be considered until all requested documentation is provided.
What are the medical provider’s appeal rights?
When a provider has filed all required documentation, the Pennsylvania Workers’ Compensation Bureau Fee Review Division will render an administrative decision and will forward it to all parties. If you disagree with the administrative decision rendered by the Bureau, you are entitled to appeal within 30 days of the decision by requesting a hearing before an Office of Adjudication hearing officer.
What To Do If You Have Questions
If you have any questions regarding the fee review filing procedures, you may contact the Fee Review Section at RA-LI-BWC-HCSRD, create a Customer Service request directly in WCAIS, or provide your inquiry details and contact information at 717-772-1900.
What To Do If The Insurance Carrier Appeals A Fee Review Determination
If the administrative decision rendered by the Bureau is that the insurance carrier is required to pay your bill or additional payments that were not made, and they file an appeal, this will likewise then lead to a hearing before a hearing officer. At this stage, you will likely need legal representation. YCL has been representing healthcare providers involved in fee review disputes for decades. We have obtained a successful outcome in over 95% of all the review disputes which we have handled.
Contact Attorney Eric P. Betzner
Attorney Eric P. Betzner oversees these cases for our office and can discuss what we can do to assist you in these situations. He can be contacted by email or by calling our office.
Call Yablonski, Costello & Leckie for a Free Consultation
If you have any questions about billing in a workers’ compensation claim, give us a call for a free consultation at (724) 225-9130 or (800) 964-2667.