The Doctor's Guide to Pennsylvania Workers' Compensation Billing
Your staff has better things to do than try to figure out how to comply with the Byzantine laws and regulations governing billing for work injuries. Even professional billing services leave thousands of dollars on the table by failing to understand the simple tools available to providers to obtain full compensation for the services they render. Download this book and start receiving what you've earned.
What You Must Do To Get Bills Paid Quickly!
For bills to be payable, the following must be sent to the workers' comp insurance company:
- Completed LIBC-9 Forms for each date of service.
- Copies or reprints of all original bills. Any CMS billing forms should have the signature of the provider or representative.
- Supporting documents for the services such as office notes or reports.
- Properly coded billing forms: UB-04 (for hospitals, nursing facilities, in-patient, and other facility providers) or CMS-1500 (for individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics). It is best if the codes correspond to the accepted work injury. Use of other codes or corresponding to body parts not accepted may result in a rejection by the carrier.
If the workers' compensation carrier has not paid a properly submitted bill OR the amount paid is lower than the amount required to be paid under the fee schedule, medical providers may submit to the Bureau an Application for Fee Review which must be filed "within 30 days following notification of a disputed treatment or 90 days from the provider's original date of billing, whichever is later." The Application must include the documents described above as attachments, plus the following, if applicable:
- If submitting a UB-04, provide a copy of the itemized bill or statement submitted to the insurer, including associated charges to the respective revenue codes for your facility.
- Any Explanation of Review (EOR) or denial you may have received.
The Application is to be filed by sending a copy to the insurer and the original to:
Bureau of Workers’ Compensation
Medical Fee Review Section
1171 South Cameron Street
Harrisburg, PA 17104-2597
For more information on the Application for Fee Review process, download a free copy of The Doctor's Guide to Pennsylvania Workers' Compensation Billing or refer to the Bureau of Workers' Compensation's guide to Procedures for Filing an Application for Fee Review.
What am I Supposed to be Paid?
The Pennsylvania Workers’ Compensation fee schedule varies by geographic area. To determine the correct amount you are entitled to receive for treatment provided to a patient with a work injury, click the Charge Classes by Zip Code link and click on the appropriate link for the location of your doctor’s Zip Code.
For example, if your practice Zip Code is “19102,” you should click on the link entitled “19001–19611.” Once you have opened the link, find the corresponding Zip Code for your practice. Next to it will be a number from 1 to 4 setting forth your geographic charge class. Write that number down.
Out-of-state medical providers are always in Class 3.
Once you know your billing category number, go to the Fee Schedule to determine the correct charge for the procedure code corresponding to the treatment provided.
For example, let’s assume the patient’s procedure code is 97530. Click on the Fee Schedule link above and look for No. 97530.
In our example, we will assume you are a Category 3 provider. You then need to find where the number “97530” falls in the Fee Schedule chart. In our case, the number was “97530”, which falls within the numbers “97018–99347.” Click on the link for “97018–99347.” Scroll below the column marked “CPT/HCPC code” to the number 97530. Under the column “Medicare Location,” look for the number 3 next to number 97530. Go to the right under the “Fee Schedule Amount” column to determine the amount the carrier owes for the service provided. Please note that the amounts in the “Fee Schedule Amount” column are stated in pennies. For example, the number “4860” corresponds to $48.60. If you have not been paid the correct amount, you may file an Application for Fee Review.
What Do We Do if Our Application for Fee Review Is Denied?
You must file a Request for Hearing to Contest Fee Review Determination by sending a copy to the insurer and the original to:
Fee Review Hearing Office
1010 North Seventh Street
Harrisburg, PA 17102-1400
We have Not Filed a Timely Application for Fee Review. Are any Other Remedies Available?
Yes. The patient is permitted to file a penalty petition in connection with the nonpayment of bills. An application for fee review does not have to be filed first.
What if the Insurance Company Has Filed a Utilization Review of My Treatment?
As discussed in greater detail in my book and in this article, the most important thing for a provider to do when a Utilization Review (UR) is filed is to send all medical records to the Utilization Review Organization (URO) in a timely fashion. Ask your patient to send a note to the URO describing how the treatment helps. If the reviewing doctor calls, you should speak with him to explain how the treatment helps your patient. Keep in mind that palliative pain relief is a sufficient basis for treatment to be considered reasonable and necessary. For greater detail on the regulations governing medical treatment review, click here.
May a Provider file an Appeal of an Adverse Utilization Review Determination?
Yes. The provider, patient or employer may file a Petition for Review of an URO determination. Instuctions for filing can be found on the bottom of the second page of the petition.
Mr. Boles, a certified specialist in Pennsylvania workers’ compensation, has been elected a SuperLawyer every year since 2007. He is graded AV Preeminent by Martindale-Hubbell, which demonstrates that his peers rank him at the highest level of professional excellence. He has a 10.0 rating, the highest possible, by AVVO, the independent lawyer rating service. Mr. Boles is a graduate of Georgetown University and Villanova Law School. He has written extensively on Pennsylvania workers' compensation and has lectured before attorneys, labor unions and advocacy groups for the disabled.
Mr. Boles is the author of:
The indispensable guide that takes you behind the courtroom doors, into the minds of lawyers and judges, and inside the old boys’ network to reveal the secrets lawyers never tell you.
A guide to benefits available to disabled workers, focusing on those who have suffered work injuries that the insurance company has denied.
A comprehensive handbook on Pennsylvania workers’ compensation, written for injured workers and their families.
A manual for healthcare staff and billing personnel on how to bill insurance companies efficiently.
A directory of the latest safety methods in nursing, one of the most dangerous professions in the United States.