On occasion a Virginia-based medical provider will accept a patient who is receiving workers’ compensation benefits under a case pending in another state. This can happen not only in areas that border other states, but also when a previously injured worker moves into Virginia. The Virginia-based medical provider may assume that reimbursement for treatment should follow the Virginia guidelines, but unfortunately this is usually not the case. In most other states, the workers compensations acts impose that state’s payment rules even when treatment occurs in Virginia. Fees schedules from other states may apply, treatment guidelines from the other state may apply, different forms may have to be completed, and reimbursement may be much less than expected.
When not governed by prior agreements with insurance networks, Virginia medical providers who treat patients from Pennsylvania, Maryland, West Virginia, Tennessee or Washington, DC will be paid according to those jurisdictions’ reimbursement guidelines. Of our neighboring states, only North Carolina requires employers to pay for medical services according to the law of the state where services were provided.
Of course, the situation can be reversed as well: Many times a patient whose claim is covered by a Virginia Workers’ Compensation Act case seeks medical treatment in another state. While this can happen in any number of circumstances, it is most common in the DC area, or in border cities like Bluefield and Bristol. In these situations, underpayment cases have to be pursued through the Virginia Workers’ Compensation Commission. In cases not subject to insurance network contracts, payment levels will be determined by Virginia’s “prevailing community rate” (PCR) standards.
Most providers will find that reimbursements for Virginia case patients will be greater than those for patients in the workers’ compensation systems of their own states. Virginia law also applies to questions of medical management, so that the treating physician controls the patient’s case without interference from an insurance company.
Whether you are a provider located inside, or outside Virginia, MeyerGoergen can help you deal with issues arising in Virginia’s workers’ compensation system.
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