I have been asked numerous times over the years, “What is the difference between all the disability programs for injured workers?”
Let’s talk first about the workers’ compensation system.
In Virginia any employer with 3 or more employees is required to carry workers compensation insurance. The policy rates are determined by the industry in which the employer operates, and its history with prior claims. When a worker is injured in the course of employment, the injured party is provided both medical benefits and reimbursement for income lost.
Virginia’s workers’ compensation system does affect the business performance of any medical practice providing treatment for work-induced injuries. Providers need to be savvy to the rules of our state’s system in order to assure that they are paid the full amounts to which they are entitled under the law.
Unlike many other states, Virginia does not specify a fee schedule for provider services. The state workers’ compensation law requires only that insurers pay either the amount billed or, if less, the “prevailing community rate.” Unless the provider signs a contract with a workers’ compensation claims processing network that specifies particular rates of payment, the insurance company has the burden of proving that amounts billed exceed “prevailing community rates.” In the absence of a signed contract or proof of overcharging, the Virginia Workers’ Compensation Commission commonly orders insurers to pay providers the full amount of their billings.
Sometimes a medical provider in one state may find itself treating a patient with a worker’s compensation claim pending in another state. Medical providers are to follow the compensation act in which the patient was injured. Virginia-based providers treating patients injured in accidents in other states may be surprised to learn that their charges will be compared to fee schedules adopted by law in, e.g., West Virginia, Tennessee, Maryland, Pennsylvania, or Washington DC. Some of these states even allow for management of the course of care by parties other than the treating physician.
On the other hand, out-of-state providers treating patients with claims in Virginia’s system will not face managed care decisions imposed from outside the doctor-patient relationship. Nor will they be subject to the application of rigid fee schedules; instead, they will be able to rely upon the presumptive validity of their own rates and bills.
There are other work injury programs that affect medical providers such as Longshore Harbor Workers Act, Jones Maritime Act, Federal Employers Liability Act, and Department of Labor/Office of Workers Compensation Programs. More to come; stay tuned.
The materials on this website are meant for informational purposes only and nothing contained in this site is to be construed as legal advice. If you need legal advice, you should contact an attorney directly. Do not act upon the information on this site without seeking professional guidance. Information on this website about specific matters or success in previous cases is not meant to be a prediction or guarantee of similar results in any other case. Each case consists of factors and applicable law unique to that case and you should consult an attorney.