Marc Abla, CAE | Oct 2, 2019 | 0
Prompt Pay and Balance Billing
Are Employers required to pay charges directly to the provider within 60 days?
- Section 8.2(d) of the Act provides that when an employee notifies a medical provider that the treatment or service is for a work-related injury, the provider shall bill the employer directly. If the employer does not dispute payment of first aid, medical, surgical, or hospital services, Section 8(a) provides that the employer shall make payment directly to the provider on behalf of the employee.
- The employer is required to pay the bill within 60 days of receipt of the bill as long as the claim contains substantially all the required data elements necessary to adjudicate the bills. Unpaid bills incur interest at a rate of 1% per month payable to the provider.
- A provider cannot hold an employee liable for costs related to non-disputed services for compensable injury and shall not bill or attempt to recover from the employee the difference between the provider’s charge and the amount paid by the employer or insurer on a compensable injury.
Am I prohibited from seeking payment of bills from the employee while the claim is pending?
- Section 8.2(e) of the Act provides a provider may seek payment of the actual charges from the employee if the employer notifies a provider that it does not consider the illness or injury to be compensable.
- If an employer notifies a provider that it will pay only a portion of a bill, the provider may seek payment of the employee up to the lesser of the actual charge, the negotiated rate, or the rate in the fee schedule.
- If an employee informs the provider that a claim is on file at the Commission, the provider must cease all efforts to collect payment from the employee.
- While the claim at the Commission is pending, the provider may mail the employee reminders that the employee will be responsible for payment of the bill when the provider is able to resume collection efforts.
- Upon final award or settlement, a provider may resume efforts to collect payment from the employee and the employee shall be responsible for payment of any outstanding bills plus interest awarded.
- The employee is responsible for payment for services found not covered or compensable unless agreed otherwise by the provider and employee.
- Services not covered or not compensable are not subject to the fee schedule (the current worker’s compensation fee schedule can be found at https://iwcc.optum.com/download.asp ).