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Thread: Pre Certs

  1. #1
    Join Date
    Aug 2008

    Default Pre Certs

    What is the law concerning Dr outside the state of Pa. Can the WorkComp refuse to pay them or refuse you in using them. My dr here in pa has send me to a dr in nyc , the workcomp refuses to pay ..Because of this I get no appointment! Its the Hospital for Special Surgery in NYC> It seems to me workmans comp would rather not see you get better and just accept some lame settlement..

  2. #2
    Join Date
    Dec 2007
    Tunkhannock, PA

    Default Re: Pre Certs

    Refusing to Pre-certification payment is not the same thing as refusing to pay. The ICs have consistently argued that until the necessary bureau forms with supporting documentation is submitted, no obligation for payment actually arises under the PA WC Act. Since the supporting documents include treatment notes, the obligation to pay can not arise before the treatment is rendered. However, there is case law that indicates failure to pre-certify payment is the same as refusing to pay if the failure to pre-certify deprives the injured worker of necessary treatment.

    In regard to out of state providers, the IC still has to pay, but there payment obligation is confined to what they would need to pay for the procedure under the PA cost containment provisions. PA doctors have to accept this amount as payment in full and cannot pursue the injured worker for the difference. It is arguable that this provision does not apply to out–of-state doctors, so you run the risk of being balanced billed when you treat out-of-state.
    Timothy D. Belt, Esquire
    Helping injured workers in Northeast Pennsylvania.

    DISCLAIMER: This post is intended as general information applicable only to the state of Pennsylvania. The information given is based strictly upon the facts provided. This post is not intended to create an attorney client relationship, or to provide any specific guarantee of confidentiality.


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