Causally Related Denial of Medical BillsMarch 2, 2020
There has been a recent change concerning Workers’ Compensation. In Pennsylvania, a recent case now permits insurers to deny a claim if the medical bill is not found to be causally related to the work injury. This type of decision can occur after Workers’ Compensation has been awarded.
If the medical provider has not provided enough support to show that the medicine or other prescribed activity or service is not related closely enough to be work-related, it may be denied and the prescriber would need to request a utilization review in order to obtain coverage from the employer.
Painkiller Cream Denial
In the case at issue, a medical provider prescribed a painkilling cream to be applied to an injured worker’s shoulder. The coverage for the prescription cream was denied. The Pennsylvania law requires that there be a causal relationship between the treatment under review and the injury which was sustained at work.
In the past, this sort of detailed denial and review was not conducted or scrutinized in this way. Previously, the court framed the issue by pointing out that the issue of causation between the injury and the workplace is separate from reasonableness and necessity of medical treatment.
In other words, causality had no relationship with whether the medical treatment was reasonable. These two issues are no longer separate and distinct from one another and causality can now play a factor into whether the treatment is deemed reasonable and necessary.
Legal Analysis of Conflicting Workers’ Compensation Opinions
Pennsylvania courts have not yet resolved the exiting conflicting opinions in this area. Under new opinion, more medical providers such as pharmacies and other health care providers, will need to provide notice and an opportunity to participate in the utilization review process and subsequent litigation.
It is questionable whether they will want to get involved since it may require obtaining legal counsel and other more complex steps for Workers’ Compensation patients to receive coverage for their prescription drugs or other medical devices.
In the most recent case, the court does not explain why a pharmacy should be able to participate in disputes linked to reasonableness and necessity in the medical field. Additionally, due process and other procedural questions arise as a result of these conflicting legal opinions in the state.
Delaware County Workers’ Compensation Lawyers at the Law Office of Deborah M. Truscello Can Assist if You Have Experienced an Injury at Work
If were injured as a result of an accident or a mishap at work, you may be eligible for compensation. Our Delaware County Workers’ Compensation lawyers at the Law Office of Deborah M. Truscello can assist you in seeking Workers’ Compensation and help determine if you have other cause for action against your employer. Additionally, we can explain the practical results of recent decisions in the courts. Contact us online or call us at 610-892-4940 to schedule a free consultation today. Located in Media, Pennsylvania, we also serve clients in Bucks County, Chester County, Delaware County, Lancaster, Montgomery County, Norristown, Philadelphia, Reading, and West Chester.