This is not an easy question to answer. Generally the employer must pay for all treatment which is designed to improve the employee’s physical condition and/or provide relief from pain. Many employees never have any problem with payment of their medical expenses, but those who do usually fall into one of two categories: they receive medical care that occurs on a frequent basis (i.e., once a week) or their medical provider uses uncommon treatment methods (i.e., certain chiropractic modalities). If either of these categories describes your treatment plan, you should realize that the employer may have the treatment reviewed under the peer review process. (See the next question).
2. What if I receive a Utilization Request?
This is the form used by the employer to have your medical treatment be reviewed to determine whether it is reasonable and necessary. (For general information on the procedures to follow, please see Section III C 1).
If you receive a decision in which the URO states that the medical treatment is reasonable and necessary, the decision affects only that treatment outlined in the decision. The decision will usually not address the need for future treatment or the treatment of any other medical providers. Thus, nothing in the law prevents the employer from filing another UR request in six months if the employee continues to receive the same treatment. Sometimes when the employer has lost once it will not try again, but this is not always so.
If you receive a decision which states that your treatment was not reasonable or necessary, you can file a petition to review the decision within 30 days of the date you received the decision. The provider has the same right to file a petition; thus you should contact their office to see if they intend to do so. If they are not going to fight the decision, you should seek legal advice as to whether you should file the petition.
3. What if I receive a medical bill which is unpaid and I have not received a UR Request;
If you receive a bill, you should call your claims representative. (The name and phone number are usually on your check stub or on your Notice of Compensation Payable). It may be that the doctor’s office has not provided the necessary records; you can facilitate payment by calling the office yourself to request that they be sent. If you have an attorney who represented you in the past, you can also contact her office about getting the bill paid.
Sometimes the problem is that the employer is claiming that your treatment is not related to your work injury. This is a different issue than whether your treatment is reasonable and necessary. An example of this is an employee who has a back injury and later seeks treatment for depression. If the employer disputes that the depression was caused by the work injury, it may deny payment of the bill without filing a UR request. In these cases, the employee can file a petition to seek payment of the treatment.
4. How long must my employer pay for my medical expenses?
If an employee is totally disabled, there is no time expiration in the law for payment of medical expenses. Note, however, that under the present definition of “total disability”, after 104 weeks the employer can require the employee to be examined to determine an impairment rating. If the impairment rating is less than 50%, the claim converts to partial disability status. If the employee remains 50% or more disabled, the presumption of total disability continues and medical treatment is covered as long as the impairment reaches this threshold.
When an employee is on partial disability status, the Act states that the total number of weeks available shall not exceed 500 weeks. At this point the employer’s responsibility for payment of wage loss benefits ends. (Reasonable and necessary medical expenses should continue to be paid). The only exception to this is if the employee files a Reinstatement Petition which alleges that her condition has worsened to the point that she has become totally disabled again.
5. What if I want to see a chiropractor and there is no chiropractor on my employer’s panel list?
You have an equal right to choose a chiropractor over a medical doctor as your treating physician. If there is no chiropractor on the panel, you can choose one yourself. However, you should notify your employer and/or the claims representative of the name and address of the chiropractor. The chiropractor should follow up by sending his records and bills to the employer/insurance company in a timely manner. If the employer disputes the treatment, you may want to consult with a medical doctor to affirm the appropriateness of the care you are receiving. Often the opinions of medical doctors are more persuasive to the claims representatives and the judges.
6. Will the bill be paid if I switch to a new doctor?
If you are still within the first 90 days of treatment, you can switch doctors, but you must choose another one from the panel. If you choose a doctor who is not on the panel during this period, the employer does not have to pay for it. After 90 days, you can stop seeing the panel doctors and you may see any doctor you wish.
