In most cases when an injured worker gets a bill for their workers’ comp injury is a “Balance Bill.” A Balance Bill is when a medical provider charges the injury worker the difference between the provider’s charge and the amount paid by the insurance company. This practice is prohibited by the PA Workers’ Compensation Act, 34 Pa. Code Section 127.211 (a), titled “Balance Billing Prohibited,” which states:
A provider may not hold an employee liable for costs related to care or services rendered in connection with a compensable injury under the Act. A provider may not bill for, or otherwise attempt to recover from the employee, the difference between the provider’s charge and the amount pain by the insurer.
The problem with “Balance Billing” lies with how the Pennsylvania Workers’ Compensation Act was written. There is a gap in the law when it comes to Pennsylvania Medical Provider as compared to out-of-state medical providers.
Most Pennsylvania medical providers are aware of the law that prohibits them from balance billing. However, when you are dealing with an out-of-state medical provider they may not be aware because Workers’ Compensation laws vary widely from state to state.
An out-of-state medical provider may not be aware or disregard the PA Workers’ Compensation laws. To further complicate this, the Workers’ Comp Act doesn’t specifically state in the section referring to Out-of-State medical treatment that Balance Billing is prohibited from these providers.
The PA Workers’ Compensation Act, 34 Pa. Code Section 127.129, titled “Out-of-State medical treatment,” states in part that:
When you treat with out-of-state medical providers who are not licensed by the Commonwealth to provide health care services, the amount that the workers’ compensation insurance company shall pay for medical treatment is capped.
The medical fee cap is based off of the Medicare reimbursement rate applicable in Harrisburg, Pennsylvania.
This amount may not cover the full amount of the cost of treatment from the provider and the out-of-state medical provider sends you a balance bill. The Act doesn’t specifically state that this action is prohibited for an out-of-state medical provider. In addition the Pennsylvania Workers’ Compensation website’s FAQ warns; “If you seek treatment outside Pennsylvania, you may be subject to the risk of balance billing by the medical provider.”
Thus leading to the “gap”, in which out-of-state medical provider can attempt to collect the balance from an injured worker.
You should immediately take action when you get a bill from a medical provider for your compensable Pennsylvania workers’ compensation injury. Whether the bill is from an out-of-state medical provider or a Pennsylvania medical provider, this is the first sign that there may be a problem with your PA Workers’ Compensation Claim.
The law firm of Calhoon and Kaminsky P.C., represents injured workers and Social Security Disability applicants throughout Pennsylvania
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For more than 20 years, our attorneys have been helping injured workers navigate the complex Pennsylvania workers’ compensation system. We empower workers with the information and the representation they need to make the best decisions for themselves and their families’ future.
