Health care providers play a vital role in the claim process. Accordingly, they have certain rights and remedies available to them under the Virginia Workers' Compensation Act.
Generally, providers become involved in a claim shortly after a work-related accident. Va. Code §65.2-603 requires that the employer provide the claimant with a panel of physicians from which to choose a treating physician. The physician chosen by the claimant becomes the authorized treating physician. Generally, the following charges may be covered where treatment is related to the compensable injury:
- Charges billed by the authorized treating physician
- Charges billed by a physician to whom the claimant is referred by the authorized treating physician
- Charges for medically necessary treatment and diagnostic measures
Va. Code §65.2-603 provides a more complete list of benefits.
The Act also provides the standard that is to be used in calculating reimbursement. Va. Code §65.2-605 states that the employer's liability for medical charges is limited to “such charges as prevail in the same community for similar treatment[.]” The term "community" is defined by reference to Commission Rule 14. There is no fee schedule in Virginia. Charge schedules agreed to by the carrier and provider will be enforced.
If a dispute arises as to reimbursement for a medical charge, the health care provider may invoke one or more of the following remedies:
- Appropriate where there has been no payment or where provider is dissatisfied with level of reimbursement
- Initial decision issued by a deputy commissioner after reviewing evidence
- Right of review by the Commission
- Appeals to Virginia Court of Appeals and Supreme Court of Virginia
- Initiated by filing a request along with supporting evidence to the Commission
When filing a request with the Commission to resolve a dispute over payment for medical services rendered to an injured worker you must:
- Send a copy of your submission to the Commission and all interested parties. These parties may include the insurance carrier or self-insured; the third party administrator if one has been assigned by the carrier or self-insured; the attorney for the latter parties; and the injured worker and his/her attorney.
- Your submission must include: the medical bills and treatment reports which are in dispute; the actual balance you are seeking; and the dates of services.
- Failure to provide copies of your submission to all interested parties and/or supporting information regarding your claim may result in rejection.
- For further information on these and other requirements, please call 1-877-664-2566.
Mediation may be requested in addition to Adjudication.
- Informal, cost-effective means of alternative dispute resolution
- Parties design their own solutions with the help of a Commission mediator
- Parties agree to mutually satisfactory solution
- Appropriate for any medical charge issue
- Initiated by written request filed with Commission in letter format or using our mediation request form.
Once the claimant has filed a claim which covers a specific charge, or once the Commission enters an award of compensation applicable to a charge, the health care provider may not attempt to bill the claimant for any part of the charge. However, if the Commission rules that the charge is not compensable under the Act, the provider may bill the claimant.
Health care providers may check the claims status for their patients by calling the Commission toll-free at 1-877-664-2566. Multiple inquiries may be sent by facsimile to 804-418-4920 or by mail the Commission's Medical Care Provider Inquiry form or on similar format.
HIPAA privacy regulations do not apply to workers' compensation. To learn more, please click on HIPAA.
The Commission has several articles that further discuss some important issues.
- Employer's Obligation to Provide Medical Treatment
- The Commission's Claims and Adjudication Processes
- The Commission's Alternative Dispute Resolution Systems
- Award of Attorneys' Fees for Recovered Medical Payments (714 Fees)
For more information, contact the Commission at 804-418-4920.