Pennsylvania Workers' Compensation Lawyer Blog

On many occasions over the years, we have addressed the Utilization Review (UR) process in Pennsylvania workers’ compensation cases. This is the process either party, usually the workers’ comp insurance carrier, uses to obtain a determination as to whether a treatment at issue is “reasonable and necessary” such that the insurance company must pay for the treatment.

What is sometimes lost in this abstract analysis is the impact a UR has on real live people. When a Request for Utilization Review is filed by a workers’ compensation insurer, the insurance carrier is immediately relieved of payment of bills for the treatment at issue, unless and until the treatment at issue is found to be “reasonable and necessary.”

Being in business for profit, or at least to make a living, not all providers are able, or willing, to continue to provide treatment once a UR is filed. One of the most dangerous areas this problem hits home is with medications.

Many medications cannot be suddenly stopped without risk of very severe consequences. Yet, when a UR is filed, frequently retail pharmacies will refuse to fill prescriptions, leaving the injured worker without the medication he or she desperately needs.

This is one of those flaws in the Pennsylvania Workers’ Compensation Act that seems so clear, and so basic, that the PA Legislature would have to fix it, right? That is what we keep thinking, but we have thus far been unsuccessful in having this issue resolved. Sadly, it may take widespread media coverage of a tragic event before things are made right.

As a general rule, the Pennsylvania Workers‘ Compensation Act requires medical providers to submit their bills to the workers’ compensation insurance carrier on the correct forms. Again, the usual rule is that the workers’ comp insurance carrier is not required to pay bills until they are submitted on the proper forms (and until supporting documentation is provided).

A recent decision by the Commonwealth Court of Pennsylvania, however, confirms the beliefs of us Pennsylvania workers’ compensation attorneys, who feel this technical step is not always necessary. In Shelton v. WCAB, decided by the Court on June 26, 2008, the workers’ compensation insurance carrier was ordered to pay medical bills even though the bills were not submitted on the proper forms.

In this case, the Court drew a distinction between the situations when the claim has already been accepted as opposed to one where there has never been liability of the workers’ compensation insurance carrier established. When the liability of the workers’ compensation insurance carrier has not yet been established, then bills must be on the proper forms. When we are dealing with an accepted claim, then this technicality may not be necessary.

One of the more commonly misunderstood aspects in the Pennsylvania Workers’ Compensation Act is the status of medical treatment within the first 90 days of the injury. Too often, an injured worker will be told by his or her employer that they must treat with a specific company doctor. This is not completely true, according to the Pennsylvania Bureau of Workers' Compensation.

If the employer follows the requirements of the Pennsylvania Workers’ Compensation Act, and properly posts a listing of healthcare providers (not necessarily doctors, more on that later), the employer is only required to pay for treatment with those listed healthcare providers for the first 90 days of treatment after a work injury.

To have the listing of healthcare providers (known as a “panel posting”) be “proper,” the list must meet certain requirements. For one thing, there must be at least six healthcare providers on the list, of which at least three must be doctors. The names, addresses, telephone numbers and specialties of each healthcare provider must be stated as well. The healthcare providers on the list must be “geographically accessible.” The list must be prominently displayed, and the employer must have the worker sign a document acknowledging that the worker saw the list at the time the worker is hired, after a change is made on the list, and after the injury.

If the listing is “proper” and the employer has followed the requirements listed above, then the workers’ compensation insurance carrier is only required to pay for treatment with those listed healthcare providers for the first 90 days of treatment. The injured worker is free to choose any healthcare provider on the panel (the employer cannot direct the injured worker to any specific healthcare provider). If the injured worker needs treatment from a specialty which is not represented on the listing, the injured worker is free to choose his or her own healthcare provider in that specialty, and the workers’ compensation insurance carrier is responsible for payment (provided the treatment is reasonable, necessary and related to the work injury).

It is also important to note that, even if the employer has a properly posted listing, the only penalty to the injured worker for going to a doctor not on the listing is that the workers’ compensation insurance carrier will not be required to pay for that treatment. There may be situations where the injured worker finds seeing his or her own physician, perhaps just a single time, worth paying the cost of the visit.

In a recent decision favorable to injured workers in PA, the Supreme Court of Pennsylvania said that, under certain circumstances, a workers’ compensation insurance company must pay not only to modify a van to be wheelchair accessible, but to pay for the cost of the van itself. This is an important change in the law, because there had been an older case, finding the workers’ compensation insurance company was only responsible to pay for making a van wheelchair accessible (and not for the cost of the van itself).

The injured worker in this case, who was paralyzed in a work injury, was not able to get out of the house, even to medical appointments, without this special van. Fortunately, the Court saw the unfairness of making the workers’ compensation insurance company pay only to modify the van for a wheelchair, when the injured worker might then not even be able to afford buying the van itself. The Court said, “ . . . the van is crucial to restore some small measure of the independence and quality of life that existed before the work injury.”

This rule is probably limited to cases like this, involving a catastrophic injury. The Court also said the situation of the injured worker in each case needs to be examined. For example, is a new van required? Did the injured worker own a van before the injury? Was any automobile owned by the injured worker before the injury? The answers to these questions, and others, would determine whether the workers’ compensation insurance company would have to pay for the cost of the van in any future case.

This case is titled, Griffiths v. W.C.A.B. (Seven Star Farms, Inc.), and it was decided by The Supreme Court of Pennsylvania on March 19, 2008.