For injured workers dealing with Pennsylvania workers’ comp medical bills, a recent Commonwealth Court decision may mean that obtaining necessary medical equipment—and getting the workers’ compensation insurance carrier to actually pay for it—becomes more difficult.
In Scomed Supply v. Hartford Accident & Indemnity Company and Sedgwick Claims Management Services, the Commonwealth Court considered whether a company that sells durable medical equipment and supplies qualifies as a “health care provider” under the Pennsylvania Workers’ Compensation Act.
The Court held that Scomed Supply did not qualify as a health care provider and therefore could not use the Workers’ Compensation Bureau’s Medical Fee Review process to challenge the amount it was paid by the insurance carrier.
That distinction may sound technical. For injured workers who depend on orthopedic devices, medical equipment and other supplies to recover from their injuries, however, the practical consequences could be significant.
What Happened in the Scomed Case?
Scomed supplied an injured worker with electrodes, batteries, lead wires, moisturizer and alcohol wipes needed to use a TENS unit that had been prescribed by the worker’s physician to treat his work injury.
Scomed billed the workers’ compensation insurance carrier, Hartford Accident & Indemnity Company. Hartford paid less than the full amount billed, and Scomed attempted to challenge those payments through Pennsylvania’s Medical Fee Review process.
The problem was not whether these supplies were part of the injured worker’s medical treatment.
Instead, the case turned on who was entitled to use the Fee Review system to challenge the insurance carrier’s payment.
Under the Workers’ Compensation Act, a “health care provider” can file for Fee Review when it disputes the amount or timeliness of an insurer’s payment. The Act defines a health care provider as a person or entity licensed or otherwise authorized by Pennsylvania to provide health care services.
The Commonwealth Court concluded that Scomed primarily provided medical goods, rather than health care services. Its accreditation as a durable medical equipment supplier, physical business location and inventory of medical products were not enough to make it a health care provider under the Act.
As a result, the Court affirmed the decision denying Scomed access to the Fee Review process.
Why This Decision Matters for Pennsylvania Workers’ Comp Medical Bills
There is an important distinction between saying that a medical supply company cannot use Fee Review and saying that an injured worker is not entitled to the medical supplies.
The Scomed decision does not hold that workers’ compensation carriers are relieved of their responsibility to pay for medical supplies that are required to treat a work injury.
In fact, the Commonwealth Court discussed the Pennsylvania Supreme Court’s decision in Schmidt, which interpreted the Workers’ Compensation Act’s reference to “medicines and supplies” broadly to include items that are part of a health care provider’s treatment plan for a work-related injury.
Instead, Scomed creates a potential problem with enforcement.
Companies supplying orthopedic devices, durable medical equipment and other medical products may now have a more difficult time directly contesting an insurance carrier’s failure to properly pay their bills through the statutory Fee Review system.
That creates an obvious practical concern.
If suppliers have difficulty getting Pennsylvania workers’ comp medical bills paid by insurance companies, they may become less willing to provide equipment to injured workers without payment upfront or some assurance that the bill will ultimately be paid.
The supplier’s billing dispute can therefore quickly become the injured worker’s problem.
What Should Injured Workers Do if Pennsylvania Workers’ Comp Medical Bills Aren’t Paid?
When an insurance carrier refuses to pay for medical treatment, medication, equipment or supplies that should be covered under an accepted workers’ compensation claim, an injured worker does not necessarily have to accept the denial.
Pennsylvania workers’ compensation law provides injured workers with another important enforcement mechanism: a petition seeking penalties against an insurance carrier that violates its obligations under the Workers’ Compensation Act.
Depending on the circumstances, penalties can be substantial. The Act permits penalties of up to 50% in cases involving unreasonable or excessive delay.
That means an injured worker whose workers’ compensation carrier fails to pay a medical bill that it is legally obligated to pay may be able to ask a Workers’ Compensation Judge not only to require compliance with the Act, but also to impose a financial penalty for the violation.
This issue is not limited to orthopedic equipment.
Problems involving Pennsylvania workers’ comp medical bills can arise when an insurance carrier fails to properly pay for medical treatment or items related to an accepted work injury, including:
- orthopedic braces and devices;
- TENS units and associated supplies;
- other durable medical equipment;
- prescription medications;
- medical treatment and services; and
- other medicines or supplies prescribed as part of treatment for the work injury.
Whether a penalty is appropriate—and the amount of any penalty—depends on the particular circumstances and the nature of the carrier’s violation. A 50% penalty is not automatic simply because a medical bill remains unpaid.
Is an Unpaid Pennsylvania Workers’ Comp Medical Bill the Injured Worker’s Responsibility?
Perhaps the most important takeaway from Scomed is that an injured worker should not assume that a medical bill is their responsibility simply because a medical supplier says workers’ compensation has refused to pay it.
The Commonwealth Court’s decision addresses the supplier’s ability to use a particular administrative process to challenge payment. It does not give insurance carriers permission to disregard their obligations to provide medical treatment, medicines and supplies required under the Workers’ Compensation Act.
The Court itself acknowledged Scomed’s concern that excluding companies like it from Fee Review could affect injured workers’ access to necessary medical supplies. But the Court concluded that changing the statutory definition of a health care provider was a matter for the Pennsylvania General Assembly—not the courts.
Until the legislature addresses that issue, injured workers may increasingly find themselves in the position of having to enforce rights that medical suppliers previously attempted to enforce on their own.
If you are dealing with Pennsylvania workers’ comp medical bills that have not been paid—or your workers’ compensation insurance carrier is refusing to pay for a prescribed medical device, medication, treatment or other medical expense related to your work injury—you should consider speaking with a Pennsylvania workers’ compensation attorney about whether the carrier is violating the Workers’ Compensation Act and whether a penalty petition or other legal action may be appropriate.
The bottom line: Scomed may have closed an avenue of relief for some medical supply companies, but it did not eliminate an injured worker’s right to medical care and supplies required by Pennsylvania’s Workers’ Compensation Act. When Pennsylvania workers’ comp medical bills that should be covered go unpaid, injured workers may need to take action to enforce their rights.