Injuries are not badges of honor, protecting your family is.

Medical Billings in L&I Claims

MEDICAL BILLINGS IN L&I CLAIMS

How L&I Medical Bills Are Processed

  • The doctor’s office takes care of the bills. They bill L&I (Labor and Industries) or the SIE (Self Insured Employer)
  • L&I or SIE pay the doctor directly
  • The injured worker will never see a bill, unless there is a problem. If the injured worker has an open L&I claim and the treatment is related to the job injury, then the injured worker should not be billed. Doctors’ bills are discounted by L&I, but the worker should not be billed the difference       WAC 296-20-015(5)(h).

If a Medical Treatment Billing is Wrongly Denied, Figure Out Why & Take Appropriate Action

  • What is the reason given for not paying? The reason should be on the remittance advice.           
    • Is it a good reason? If not request reconsideration of their decision.
    • Is the billing in proper form?
  • Is coverage being denied for a good reason?
    • They are allowed to do this if they have scientific or factual support for their refusal to pay.
    • Is a bogus IME all they have? Don’t let them get away with that. If a treating doctor has knowledge that an IME is inaccurate, that doctor needs to speak up and make it right.
  • Is the billing for controversial treatment?
  • Does this treatment require authorization? WAC 296-20-03001
  • Is there a current and valid PPO contract governing bill payment? If there is a valid PPO contract on the date of service and it does not exclude workers’ compensation, then if valid it controls billing.
  • Take appropriate action if a bill is wrongly denied. Request reconsideration in writing.

SOLUTIONS FOR WRONGLY DENIED BILLS       

         L&I and the self-insurer are regulated by and should follow the law. The following questions and answers will help with understanding the law and getting treatment bills paid.

  1. Is the Self Insurer or L&I refusing to pay bills or refusing to pay a benefit in a timely fashion? – They are not allowed to do this so don’t let them get away with it. They can be assessed a 25% penalty, in favor of the injured worker.
  2. Is L&I or the Self Insurer paying late? – Interest is due. The SI 51.36.085 and L&I RCW 51.36.080 must pay medical bills within 60 days of receipt of proper billing on an allowed claim. If they do not pay on time then interest is due and shall be paid at the rate of 1% per month.
  3. Is the Self Insurer trying to negotiate the fee schedule? They are not allowed to do this. They must pay per the fee schedule.
  4. Take appropriate action if a bill is wrongly denied. Talk to your claims manager or bill payer. If that does not work then request reconsideration in writing, or file a written appeal to the BOIIA (Board of Industrial Insurance Appeals). You must protest or appeal in time, or you lose your right to do so because of the time limitation placed on protest and appeal rights.

INFORMATION JUST FOR DOCTORS AND OTHER MEDICAL PROVIDERS

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