PA Workers’ Compensation Insurance Carrier Must Pay Bill for Medical Treatment or Seek Utilization Review

Under the Pennsylvania Workers’ Compensation Act, the insurance carrier has 30 days to either pay a medical bill for treatment related to a work injury, or file for Utilization Review (to challenge whether such treatment is reasonable and necessary).  The question, at times, is whether the treatment is “related” to the work injury or not.  Some workers’ comp insurance carriers simply deny payment, alleging the bills are for treatment unrelated to the work injury.  A recent decision by the Commonwealth Court of Pennsylvania casts doubt on this type of response.

First, it is important to note that this decision is “unreported,” and is only persuasive (not binding).  In Pennsylvania Liquor Control Board v. 3B Pain Management (Bureau of Workers’ Compensation Fee Review Hearing Office), the injured worker fell in the parking lot outside the store.  A Claim Petition was filed and litigated.  Ultimately, the Workers’ Compensation Judge granted the Claim Petition, finding the work injury to be a “meniscal tear of the right knee and chondromalacia of the femoral and tibial condyle of the right knee.”

The injured worker had chiropractic treatment, which the Court described as, “ . . . spinal manipulation relating to low back pain, manipulation of Claimant’s knees and his right hip for pain, low level laser treatment on his right knee, and therapeutic massage for unidentified muscle spasms.”

Bills for this treatment were sent to the workers’ compensation insurance carrier.  Payment was not made, so the provider filed for Fee Review.  The insurance company defended the Fee Review by alleging that the treatment at issue was not related to the accepted work injury (solely the right knee).  A Hearing Officer (the person who decides Fee Reviews) found the bills payable, since the insurance carrier failed to either seek Utilization Review or file a Petition to Review Medical Treatment.  The Hearing Officer concluded that relatedness is not an issue appropriate for the Fee Review process.

Upon appeal to the Commonwealth Court of Pennsylvania, the decision of the Hearing Officer was affirmed.  The Court found that the insurance carrier cannot simply refuse to pay a properly submitted bill, alleging it to be unrelated to the work injury.  Instead, the insurance carrier should be seeking Utilization Review.  While it is true that Utilization Review is solely to determine whether treatment is reasonable and necessary, and cannot address causal relationship, the Court concluded that the insurance carrier is, in a way, challenging whether the modalities at issue are reasonable and necessary medical treatment for the accepted work injury.

Specifically, citing prior case law, the Court stated:

“Here, Employer’s claim ‘that the [disputed treatment] was not related to Claimant’s work injury ‘was just another way of stating that [it] was not a reasonable or necessary ‘procedure’ for treating Claimant’s ‘diagnosis[.]’ Id. Employer ‘was obligated to seek [UR] to dispute liability for Claimant’s treatment’ and it did not do so. Id. Accordingly, the Hearing Officer properly determined that Provider was entitled to reimbursement for all of the treatment it provided to Claimant.”

Though this is an unreported case, it would seem that a workers’ compensation insurance carrier would now be taking a great risk by simply refusing to pay a properly submitted medical bill on the basis of it being unrelated to the accepted work injury, without filing for Utilization Review.