Medical Treatment Need Not Be Pre-Approved Under PA Workers’ Comp

Previously on this blog, we have discussed the rights held by injured workers in Pennsylvania to choose their own medical providers.  This is only one area of confusion in the wacky world of medical benefits under the Pennsylvania Workers’ Compensation Act (Act).

A common complaint we get from an injured worker is that, “They are denying my medical treatment.”  In this situation, “they” is almost always the workers’ compensation insurance carrier.  And the word “denying” may or may not be accurate.

Under the Act, the workers’ comp insurance carrier has 30 days to either pay a medical bill or institute Utilization Review (the tool used to challenge whether medical treatment is reasonable or necessary), provided the bill is properly submitted by the medical provider (including supporting documentation).  As you can see, this means the workers’ compensation insurance company need not give an opinion on how they view treatment until it is actually performed.

Let’s take a step back now, and examine how the real world functions.  In a news flash (apparently unknown to legislators who drafted the Act), medical providers want to make sure they will be paid.  To that end, many healthcare providers will not perform treatment until they receive pre-approval from an insurance carrier (whether that be private health coverage or workers’ compensation).  Unlike the private healthcare system, there is no pre-approval in the workers’ compensation setting.  While a workers’ compensation adjuster cannot tell a provider that they will not pay for treatment, the adjuster can simply refuse to speak to the provider, or provide no assurances at all.

Many times, this can leave the injured worker struggling to obtain medical treatment necessary to his or her recovery.  What can be done?  For one thing, as counsel to the injured worker, we may reach out to the insurance carrier and try to get some form of pre-approval.  Or, perhaps we would educate the healthcare provider on how the system works, and help them provide treatment, then get their bills paid.  Or, at times, we may need to file our own (prospective) Utilization Review, to get a declaration that some intended treatment is “reasonable and necessary.”

The important take away here is that medical treatment under the Pennsylvania Workers’ Compensation Act is neither simple, nor, necessarily, easy to obtain.  Having an attorney involved, especially one Certified as a Specialist in Workers’ Compensation Law, can make that process easier.  And, that can be the difference between recovery and a lasting disability.