Reimbursement to Medical Providers in Workers Compensation

Did you ever wonder if the amount paid by the workers compensation carrier was all your practice could receive? Have you ever thought that you were entitled to more money for services rendered? If so, you should consider filing an Application with the Division of Workers Compensation for payment of your usual and customary bill.

A carrier is required to pay for treatment that is medically necessary and that is causally related to the accident. If you do not have a contract with the insurance carrier, then you are entitled to the usual, customary and reasonable rate for the services rendered. “All fees and other charges for such physicians’ and surgeons’ treatment and hospital treatment shall be reasonable and based upon the usual fees and charges which prevail in the same community for similar physicians’, surgeons’ and hospital services.” N.J.S.A. 34:15-15.

The process to file an application for reimbursement of medical bills can be daunting. Typically, the medical provider will need to file a “Medical Provider Application for Payment or Reimbursement of Medical Payments”. The Division of Workers Compensation has sole jurisdiction over disputed medical payments for treatment rendered to workers as a result of a work related injury. A Medical Provider Application can be filled out on the computer and electronically filed with the Division of Workers Compensation. Once the application is submitted, the carrier will automatically be served with the application and should assign counsel to file an Answer. Often a carrier will have an adjuster contact the applicant or the applicant’s attorney to see if the matter can be settled. If a settlement cannot be reached, an Answer will be filed and settlement negotiations can begin. From time to time, the carrier will request that certain discovery be provided prior to engaging in settlement negotiations. This discovery may include examples of prior billing and payments by other carriers for the same bills. This may also include copies of the bills, any appeals filed, and the associated medical records. It is important to have all necessary documentation before filing the Application.

Unpaid balances can add up to a substantial amount of lost revenue for your practice. Therefore, if you feel that you have received less compensation than what is considered usual, customary and reasonable for the services that you provided, you should contact an attorney to discuss your options.

By: Patricia Lynn Howlett, Esq.