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The workers’ compensation insurance company (the insurer) will pay
for medical treatment and prescriptions for your injury or occupational
disease. However, the insurer will not pay any medical bills until your
claim is accepted or denied. The insurer has 60 days to
accept or deny your claim.
If
your claim is accepted
The insurer will pay for injury-related medical treatment and prescription
drugs. Transportation, meals, and lodging necessary to visit medical offices
will be reimbursed within limits set by Oregon Administrative Rules. Your
doctor will bill the insurer directly. Some insurers now pay pharmacies
directly for drugs. Be sure to keep receipts for all out-of-pocket
expenses. Send a written request for reimbursement with proof of expenses
to the insurer within two years.
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If
your claim is denied
The insurer will not pay your medical bills (including bills for services
prior to the denial), with the following exceptions:
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1.
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If you are required by the insurer to receive treatment from a managed
care organization (MCO), the insurer will pay your medical bills during the time before your claim is denied.
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2.
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If you have personal health insurance, the insurer may pay charges not covered by your health insurer for necessary medical care
unless your claim is denied within 14 days. These costs may be recovered from future claims.
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If your claim is denied based on an independent medical examination (IME), and your own doctor doesn’t agree with the IME report, you may request a hearing on the denial and request a medical examination by a doctor selected
by the Workers’ Compensation Division. This is called a worker-requested medical examination.
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Before
your claim is accepted or denied
No one should pay for medical expenses while waiting for the decision
on the claim. If the insurer accepts your claim, the insurer will pay
for medical care related to the claim. If the claim is denied, you or
your private health insurance carrier will be responsible for medical
expenses. However, as of January 1, 2002, a claim that is denied and is
on appeal will be processed by the health insurance company, provided
you have coverage. However, if there is a balance remaining, the health
care provider can bill the workers’ compensation carrier, who will
pay up to the fee schedule for certain types of medical services prescribed
to reduce pain, diagnose the condition or prevent disability. If the claim
denial is ultimately upheld, the amount paid to the health care provider
can be held as an overpayment and deducted from future workers’ compensation
benefits with the same insurer.
By law, if you are receiving medical care in Oregon, the doctor may not
seek payment from you for the medical treatment related to the claim during
the time the claim is being evaluated or if the claim is accepted. It
is also important to know that during the time the claim is being evaluated
(deferred), the insurer will not make payment for any medication the doctor
may prescribe or for any other expenses such as transportation costs for
visits to the doctor’s office. You should keep receipts for these
expenses as they will be paid by the insurer, in addition to related medical
bills, if your claim is accepted. If the insurer sends you for an evaluation
during this “deferred” period, the insurer will reimburse expenses
to attend the appointments.
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Payment
for independent
medical examination (IME)
The insurer pays all costs of an independent medical examination.
If you need advance payment of your costs to attend the examination, be
sure to request the advance as soon as possible.
You
may have a family member or friend accompany you during the examination,
if you have the signed observer
form and give it to the doctor. However, doctor approval is required
for an observer in psychological exams. The insurer will not pay any expenses
for the family member or friend.
Payment
for worker
requested medical examination
The insurer pays all costs for a worker requested medical examination.
Prescriptions
The insurer will reimburse you for prescription costs for those prescriptions
directly related to your injury or occupational disease (referred to as
accepted condition(s)). Insurers are required
to reimburse you within 30 days of receipt of your written request for
reimbursement.
The insurer will notify you at the time of your claim acceptance that
actual and reasonable costs for prescriptions paid by you will be reimbursed
upon request. The insurer may require reasonable documentation to support
your request. If the insurer cannot determine if the prescription costs
are related to your accepted injury or disease, the insurer will inform
you what information is needed before the request for reimbursement can
be processed.
How
workers’ compensation insurance interacts with your health insurance
If you have personal health insurance, the workers’ compensation
insurer may pay charges not covered by your health insurance for necessary
medical care unless your claim is denied within 14 days. These costs may
be recovered from future claims with this insurer.
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