Section 13, Chapter 152: Rate of Payment by Insurers, Review of Clinic Health Care Providers, Health Care Services Board

While most of the workers’ compensation information pages deal with the payment for lost wages, another important aspect of many Boston workers’ compensation cases deals with the payment for health care services necessary to treat a workplace injury. Section 13 of Chapter 152, Massachusetts Workers’ Compensation Act, tells us how this aspect is handled.

Medical expenses can cost much more than you might imagine – often times dwarfing the amount of worker’s lost wages. As a result, workers’ compensation insurance companies often put up a vigorous fight over these benefits. Consider that a person seriously injured on the job could easily – and quickly – rack up more than $200,000 in medical bills after surgeries, drug therapies, occupational therapies and more. For most workers, this is more than they would make in several years.

Given the cost of medical care, it’s not uncommon for workers’ compensation insurers to completely disregard or attempt to discredit the opinion of your treating physicians. While your treating physicians may have the most hands-on involvement with your case, understanding full well the cause of injury or illness and your lack of ability to return to work, the insurer may insist you submit to an “independent” medical examination from a doctor of the insurer’s choosing. As our Boston workers’ compensation attorneys can explain, this doctor may or may not see you in the flesh. They could merely review your existing medical records and write a report known as a records review. More often, they’ll schedule a brief physical and will then write an Independent Medical Examination (IME) report. The IME doctor may offer an opinion contradicting that of your treating physician, arguing your injuries are not as severe as claimed or that certain procedures or treatments are not medically necessary.

While these doctors are supposed to be independent and use their own unbiased judgment, they know where their money is coming from and are rarely found for the injured worker. Interestingly, these physicians are more likely to write a negative report for workers’ compensation claims than for Social Security Disability Insurance (SSDI) cases.

One reason for this may be because an administrative judge (AJ) at the Massachusetts Division of Industrial Accidents (DIA) is unlikely to hear the testimony of a treating physician or insurance company medical examiner. Under Massachusetts General Laws Chapter 152, Section 11A, the judge is only permitted to consider the report of a court-appointed Impartial Physician when deciding the medical aspects of a case at a hearing in one of the DIA locations (Boston, Fall River, Worcester, Lawrence, Springfield). The reports or testimony from the treating physicians or the insurance company’s doctors may not be used as evidence, but the reports can be used to cross-examine or otherwise impeach the so-called impartial medical examiner during his or her deposition. The judge can also consider outside medical evidence, from a treating physician or insurance company medical examiner, if the Section 11A impartial report is deemed inadequate.

Chapter 13 Section 152 is entitled “Rate of payment by insurers; review of clinical health care providers; health care services board.” This section, as the name implies, deals with how the employee will be compensated for past and future medical expenses related to the Boston workplace injury. There is a specific office known as the Division of Health Care Finance and Policy that will set the rates of compensation. There is a very complicated formula for how certain payments will be made pursuant to other sections and chapters of the MGL.

One major portion of Massachusetts General Laws Chapter 152, Section 13 sets forth a rule which prevents the workers’ compensation insurance company from being liable for any medical expenses that are higher than the maximum amounts set by the Division of Health Care Finance and Policy. The rule applies to bills from inpatient and outpatient medical providers that offer medical services, including such things as physical therapy, occupational therapy, and speech therapy. Each medical service has a medical billing service code that is used when processing the charges. For example, the service codes actually listed in the statute are 170810 through 178013, 17850 through 17859, and 178090 through 178093.

Section 13 also outlines administrative requirements for obtaining coverage of your medical bills. For example, the health care provider who is performing the medical services must submit a fully detailed description of the required medical procedure, they must list their doctor or other healthcare worker’s license number, include a description of why the particular service is actually necessary, and then must sign the request.

One of the things we tend to see with regard to this section is when a workers’ compensation insurance company tries to claim that a procedure is not medically necessary. They may try to claim that the procedure is merely an elective procedure and not required to improve the health of the patient with regard to an injury suffered on the job. The insurance company might try to argue that the procedure is experimental and not proven to work and that there are cheaper alternatives. We also have cases where the insurance company argues that the patient has reached his or her maximum medical improvement (MMI). An individual reaches MMI when the patient has received all reasonable and available treatment and it is not feasible to do any further procedures. When this occurs, an insurance company will often try to modify an existing workers’ compensation order to have the injured worker given a permanent incapacity rating. The incapacity rating is used to calculate how much of a loss of function the injured worker has.

There is a good chance you may be feeling confused after reading the last few paragraphs. You may still not understand what it all means. You’re not alone: The statute has been written in a way that is very difficult to comprehend. This is even true for attorneys who do not do a lot of workers’ compensation cases. For this reason, the best thing you can do is speak with a Boston workers’ compensation attorney who regularly handles these matters, has the experience to fully comprehend the law and knows the best way to make sure your interests are protected.

Some large firms will simply do whatever they can to get you any level of benefits and move on to other cases. These firms want to handle as many cases as they can as fast as they can. The size of a client’s recovery doesn’t matter to them, even if they only get a little money on most cases, because they are essentially running a volume business. They count on having as many of these small recoveries as possible, without trying to get the best results for their client.

Make sure you have an attorney who understands just how important your case is to you. Make you have an attorney that will do everything within reason to increase the chances that you will receive a full and appropriate workers’ compensation benefits award. Make sure you contact the Jeffrey Glassman Injury Lawyers. Our dedicated firm is committed to ensuring not only that you receive just compensation, but that your health does not suffer because your employer’s workers’ comp insurer is trying to cut corners, putting their profits before people.

Contact Jeffrey Glassman Injury Lawyers today for a free and confidential consultation.