Fourth Quarter 2020
By: Alex Georges
In a compensable Indiana workers compensation claim, can a medical provider seek reimbursement from an employee?
No, in Indiana an authorized medical provider is prohibited from attempting to collect payment from the employee for services furnished in treatment of a workplace injury that is compensable. However, there are procedures by which the medical providers can seek payment from the employee or employer which will be explored in the next newsletter.
Pursuant to the Indiana Worker’s Compensation Act (“Act”), in a compensable worker’s compensation claim, an employer (including insurer or administrator) must provide reasonable and necessary medical care via an authorized medical provider at no cost to the employee. I.C. § 22-3-3-4 states:
After an injury and prior to an adjudication of permanent impairment, the employer shall furnish or cause to be furnished, free of charge to the employee, an attending physician for the treatment of the employee’s injuries, and in addition thereto such services and products as the attending physician or the worker’s compensation board may deem necessary.
I.C. § 22-3-3-5(c) vests exclusive authority to order payment for medical treatment for compensable injuries with the Worker’s Compensation Board of Indiana. Further, I.C. § 22-3-3-5.1 prohibits a medical service provider from knowingly collecting or attempting to collect payment from an employee, an employee’s estate, or an employee’s family members for medical services or products covered under the Act. This section of the Act also provides for a civil penalty from one hundred dollars ($100.00) to one thousand dollars ($1,000.00) for each violation of this provision.
All bills for authorized treatment must be presented to the employer or its carrier/administrator in a detailed line item form within one hundred twenty (120) days of service. 631 I.A.C. 1-1-32(2)(A)(i). The employer/carrier/administrator must pay the amount required subject to permissible review within ninety (90) days after receipt. 631 I.A.C. 1-1-32(2)(A)(ii). “Receipt” of the bill is established by either the payer’s date stamp or electronic acknowledgement date or, otherwise, is presumed to occur three (3) days after the date the bill was mailed to the payer’s correct address. Id. If less than the full bill is paid, the employer must provide an explanation of review (EOR) to the medical provider. 631 I.A.C. 1-1-32(2)(A)(iii).
Should the employer refuse to pay part or all of a provider’s bill, then the provider’s recourse is to file a Provider Fee Application for Adjustment of Claim, which is discussed further in the next newsletter.
It should be noted that, if the employee’s worker’s compensation claim be denied, then the employee is responsible for payment of all his/her medical bills. In this situation, the provider would be allowed to use whatever means it typically employs in collecting reimbursement for treatment provided. Additionally, if a worker’s compensation claim is settled on a disputed basis under IC 22-3-2-15, the parties must designate who is responsible for payment of medical treatment.
Early selection of authorized medical providers is key. Because the Act gives Indiana employers the right to select the attending physician, it is important to select providers who not only provide reasonable and appropriate medical care, but whose billing practices comply with the Act and who promptly present bills and related records for payment.