PA Workers’ Comp Insurer Assessed Penalty for Non-Payment of Medical Bills

When an injured worker in PA gets medical treatment for his or her work injury, and a bill is submitted to the workers’ compensation insurance carrier, the insurance carrier has three choices.  They can pay the bill (within 30 days), initiate the Utilization Review process (to challenge whether the treatment is reasonable and necessary), or it can dispute relatedness by filing a Petition to Review Medical Treatment.  Or, it would seem, there is a fourth option – just ignore the bills.  This one, however, often ends poorly for the workers’ comp insurance carrier.

Recently, the Commonwealth Court of Pennsylvania issued a decision in Mason v. Workers’ Compensation Appeal Board (Philadelphia AFL-CIO Hospital Association and Rodriguez), where this issue was addressed.  It is important to note, right from the start, that this is an “unreported” decision.  Previously on this blog, we mentioned that “unreported” decisions are not binding on a Workers’ Compensation Judge (WCJ), but can be persuasive and are still sometimes helpful to see how the Court views an issue.

In this case, the injured worker twisted his low back while doing his job.  The injury was accepted as “low back strain.”  The injured worker began to receive medical treatment, and the providers coded the bills for diagnoses of “lumbosacral strain/sprain, lumbosacral radiculopathy, and lumbar HNP (herniated nucleus pulposus).”  The workers’ compensation insurance company elected to not pay the medical bills, taking the position that the injured worker did not prove the work injury consisted of more than a low back strain.  Since the treatment was for diagnoses other than the accepted diagnosis, the insurance carrier felt the medical treatment was unrelated to the work injury.

A Penalty Petition was filed and litigated (in addition to a Petition for Review of Utilization Review Determination, but this petition is not relevant to our discussion).  The WCJ granted the Petition for Penalties, finding the diagnoses listed by the providers were related to the work injury, despite the description of injury actually accepted (just low back strain).

This decision of the WCJ was reversed on appeal by the Workers’ Compensation Appeal Board (WCAB).  In proving that medical bills related to the work injury were not paid, said the WCAB, the injured worker had the burden to prove the diagnoses listed by the providers were actually related to the injury.  By not presenting medical evidence, the injured worker failed to meet the required burden of proof.

Upon further appeal, the Commonwealth Court of PA reversed the WCAB, finding that the WCJ was correct to grant the Petition for Penalties.  The evidentiary record already established that there was an injury to the low back.  The injured worker merely needed to prove that the bills were for the low back injury, which was done.  Just because a different diagnosis is mentioned on the medical bills, if it pertains to the same area of the same body part, the workers’ comp insurer would need to prove the new diagnosis is not work-related.  As the Court cited from a previous case, the medical bills still had to be paid since, “claimant’s ‘injury did not change but, rather, the diagnosis of that injury changed . . . ‘”  The Court then concluded by saying, “The evidence demonstrates, instead, that the procedures were administered to treat and remedy Claimant’s back injury and, as such, indicates that there is a causal relationship between the treatments and work-related injury.”  With proper evidentiary support, the decision of the WCJ, granting the Penalty Petition, was appropriate.

So, while this opinion is “unpublished,” and merely persuasive, rather than binding, on WCJs, the reasoning of the decision should help the WCJ make the correct decision when facing this issue in the future.  And, anything that assists in getting the medical bills of the injured worker paid is good with us!

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