By Chad McDonald, Esq.
Insurance adjusters constantly receive medical bills from claimants and their attorneys demanding that payment be made to clear up a balance. These bills are usually in the form of a statement sent to the claimant by the medical provider. This can be an important issue since Board Rule 203 prescribes that requests for reimbursement of medical services be paid within 30 days of receipt. It is also important due to an increase in the number of hearings requested for the singular issue of medical bill payment (not to mention improper requests for PMT calls on medical bill payments). As discussed below, a patient’s billing statement alone does not conform to Board and fee schedule requirements and will not trigger the 30 day payment requirement.
Employers and insurers are under no burden to ensure that submissions for reimbursement of medical expenses are timely or correct. Board Rule 203(b)(1) assigns the burden of submitting reimbursements for health care goods and services and other medical expenses to the “medical provider” and “employee.”
When a billing statement or incomplete documentation is submitted from a claimant or the attorney requesting reimbursement, adjusters can cite Board Rule 205 to request proper documentation. Board Rule 205 requires forms and reports from providers that contain specific details. Acceptable forms are the Board’s Form WC-20(a), 1500 Claim Form, UB-04 or American Dental Association Form 2012 and supporting narrative (medical records), if any. The forms must be properly completed with itemized procedure (CPT) and diagnoses codes. When a claimant’s attorney simply provides a bill with no accompanying itemized charges, the employee’s burden is not met.
The Rule also requires that all requests must be submitted within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later. Failure by the medical provider or employee to submit expenses within the time prescribed shall result in waiver of such expenses and the insurer may refuse payment.
Insurers who receive improper requests have both a defense and an obligation under the Rules. Rule 203(c)(3) provides that the failure of a provider to include with submission of charges the reports or other documents required by the Board, constitutes a defense to the employer or insurer’s failure to pay. However, the employer or insurer must submit to the health care provider or employee written notice indicating the need for further documentation within 30 days of receipt of the charges or within 15 days of an itemized written request for mileage incurred by the employee. An employer or insurer’s failure to do so will be deemed a waiver of the right to defend a claim for failure to pay such charges in a timely fashion on the ground that the charges were not properly accompanied by required documentation.