Fourth Quarter 2020
By: Joshua Stegeman
In a compensable Missouri workers compensation claim, can a medical provider seek reimbursement from an employee?
No, in Missouri a medical provider cannot seek reimbursement from an employee in a workers’ compensation claim if the employer/insurer has provided notice to the medical provider that the medical treatment is related to the worker’ compensation claim. However, if no notice is provided to the medical provider, then the medical provider may seek reimbursement from the employee or the employee’s group health insurance for treatment related to work injury. There are procedures by which the medical providers can seek payment from the employee or employer which will be explored in the next newsletter.
In Missouri, the prohibition against a medical provider seeking reimbursement from an employee is covered under Section 287.140.13(1) RSMo which states:
Other than the healthcare provider selected by the injured worker at his or her expense, when the employee, employer or the employer’s insurance has notified the provider in writing of the injury being workers’ compensation related “no hospital, physician, or other health care provider. . .shall bill or attempt to collect any fee or any portion of a fee for services rendered to an employee due to a work-related injury.
If the injury is found to be non-compensable, the healthcare provider shall be entitled to pursue the employee for any unpaid portion/s of the fees or other charges for services provided to the employee.
Also, Missouri statutes state an employee shall never be a party to a dispute over medical charges; this implies that the provider shall not involve the employee in any dispute. Regardless of whether the case is a direct pay dispute or a reasonableness dispute, Section 287.140.4, RSMo makes clear, “The employee shall not be a party to a dispute over medical charges, nor shall the employee’s recovery in any way be jeopardized because of such dispute.”
Additionally, Missouri provides a statute regarding the reasonableness of medical providers’ fees. All fees and charges under Missouri’s Workers’ Compensation Law per Section 287.140.3 RSMo “shall be fair and reasonable, shall be subject to regulation by the Division or the Commission, or the Board of Rehabilitation in rehabilitation cases. A healthcare provider shall not charge a fee for treatment and care which is. . .greater than the usual and customary fee the provider receives for the same treatment or services when the payor for such treatment or service is a private individual or a private health insurance carrier.”
Finally, Missouri provides two different ways for a medical provider to seek payment of a medical bill in Missouri if there is a dispute. The two ways are through a 1) Medical Fee Dispute or 2) Application for Payment of Additional Reimbursement of Medical Fees. We will discuss those two processes in more detail in the next newsletter.
If a medical provider seeks medical reimbursement from an employee regarding a compensable claim, we suggest that you write to the provider and advise them they cannot pursue reimbursement from the employee since the medical treatment is reasonable and necessary and thus compensable. In addition, if payment has already issued for the claim and the medical provider merely has a dispute about the amount paid, then you could offer reconsideration and resubmission of the bill for additional payment to avoid suit. But we do not recommend proposing this in the letter providing notice to the medical provider that they cannot seek payment from the employee. This will force the medical provider to do the heavy lifting and make the inquiry if they wish to obtain further payment. If the medical provider elects to file suit, we can handle the defense of those matters.
If you are handling a compensable claim, advise the medical provider of the reasonableness and necessity of the medical provider’s treatment as it relates to the workers compensation claim. This should avert the medical provider seeking reimbursement from the employee directly. If a dispute exists regarding the reasonableness or necessity of medical treatment, then we recommend against providing notice to the medical provider to avoid inadvertently “authorizing” otherwise disputed treatment.