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.
Virginia’s Workers’ Compensation medical fee schedules (MFS) establish the maximum liability of an employer/insurer for most medical services rendered to injured workers on or after January 1, 2018, regardless of the date of injury. Separate fee schedules have been developed for 7 different provider types and 6 geographic communities within Virginia. The liability of an employer/insurer for medical services rendered prior to January 1, 2018, is limited to “such charges as prevail in the same community for similar treatment when such treatment is paid for by the injured person.” This is called the “prevailing community rate” standard. Additional information and exclusions to the MFS can be located in the Ground Rules Document.
Va. Code §65.2-605 provides a complete listing of the employer's liability for medical charges prior to and after the transition.
If a dispute arises as to reimbursement for a medical charge, the medical provider may invoke the following remedies:
- Administrative Review and Determination
- Required for all dates of service on or after 01/01/2018
- Administrative review process – Any dispute concerning the application of the Virginia fee schedules and ground rules to a particular medical service shall be submitted to the Commission for an administrative review and determination according to such procedures as the Commission may adopt from time to time.
- Finality – An administrative decision of the Commission issued pursuant to subsection A of this Section shall be final and binding 30 days after its issuance unless a request for hearing is made pursuant to subsection B of this Section
- Alternative Dispute Resolution (Mediation)
- The Alternative Dispute Resolution (“ADR”) Department provides voluntary and confidential informal dispute resolution processes where a neutral third party (mediator) facilitates communication to assist the parties in mediating an agreeable solution. The purpose of mediation is to identify issues, clarify misunderstandings, explore solutions and mediate an agreement. Any party to a claim may request mediation to resolve a dispute quickly or to negotiate the compromise settlement of a claim. Mediation can be requested at any time and most issues can be mediated if all parties are agreeable.
- Judicial Review
- If a request for hearing is made to the Commission within 30 days after issuance of an administrative decision, the dispute shall be referred to the appropriate hearing docket and adjudicated in the same manner as change-in-condition claims, with the same rights of review and appeal as set forth in Sections 65.2-705 and 65.2-706 of the Code of Virginia and subject to the applicable Rules of the Commission.
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. Click here to learn more about HIPAA.
The Commission has several articles that further discuss some important issues.
- The Commission’s Claims and Adjudication Processes
- Award of Attorney’s Fees for Recovered Medical Payments (714 Fees)