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Balance Billing and Workers’ Compensation in Pennsylvania
July 27, 2022
By John W. Zatkos, Jr. Esquire
What if I get a surprise health care bill while being treated for a work injury?
Balance Billing is when a provider charges a patient with the amount the insurance company doesn’t pay. Balance Billing is prohibited by the Pennsylvania Workers’ Compensation Act. Pennsylvania Code (34 PA Code § 127.21) says “A provider may not bill for, or otherwise attempt to recover from the employee, the difference between the provider’s charge and the amount paid by an insurer.” However, there are some instances where an injured worker may receive a balance billing invoice.
Balance Billing and Out-of-State Providers
The first is if they have treated with an out-of-state provider. This may be an issue for some of our clients who work in Pennsylvania but live in West Virginia or Ohio. An out-of-state provider may not be familiar with the Pennsylvania Workers’ Compensation Act. The Act says:
(a) When injured employees are treated outside of this Commonwealth by providers who are licensed by the Commonwealth to provide health care services, the applicable medical fee cap shall be as follows:
(1) If the provider is both licensed by and has a place of business within this Commonwealth, the medical fees shall be capped based on the Medicare reimbursement rate applicable under the Medicare Program for services rendered at the provider’s primary place of business in this Commonwealth, subject to § 127.152 (relating to medical fee updates on and after January 1, 1995-generally).
(2) If the provider is licensed by the Commonwealth to provide health care services but does not have a place of business within this Commonwealth, medical fees shall be capped based on the Medicare reimbursement rate applicable in Harrisburg, Pennsylvania, under the Medicare Program for the services rendered subject to § 127.152.
(b) When injured employees are treated outside of this Commonwealth by providers who are not licensed by the Commonwealth to provide health care services, medical fees shall be capped based on the Medicare reimbursement rate applicable in Harrisburg, Pennsylvania, under the Medicare Program for the services rendered subject to § 127.152.
Balance Billing and Contested Workers’ Compensation Cases
The second instance of Balance Billing is when the injured worker’s case is contested and they are using their private insurance while the case is being litigated. In these instances, we have seen insurance companies who attempt to bill the employee for their workers’ compensation treatment. We advise retaining us as your Workers’ Compensation attorneys so we can invoke a special Department of Labor memo on your behalf, which may help. We simultaneously may file a petition on your behalf to ensure that your entire claim/injuries are acknowledged.
If you receive a surprise bill when being treated for a Workers’ Compensation injury in Pennsylvania, contact your lawyer, who will be able to counsel on the best course of action. Rothman Gordon is always ready to assist people injured on the job. Contact us online or call (412) 338-1177.