When an employee is injured on the job, the employer or insurer is required to provide the medical treatment and care to cure and relieve the employee from the effects of the injury. This includes all costs for authorized medical treatment, prescriptions, and medical devices. There is no deductible and all costs are paid by the employer or its workers’ compensation insurance company. The employer has the right to choose the healthcare provider or treating physician, however, the employee has the right to select a treating physician at the employee’s own expense. Regardless of whether the employee or employer chooses the treating physician, under the Missouri Workers’ Compensation Law, healthcare providers “shall have the affirmative duty to communicate fully with the employee regarding the nature of the employee’s injury and recommend treatment exclusive of any evaluation for a permanent disability rating.” Section 287.140 RSMo.
Forms to be Filed
Medical Treatment Form (WC-9) needs to be filled out by the treating physician indicating what treatment was provided to the injured worker as well as all results. This form will need to be forwarded to the employer or employer’s insurance company at the time of the initial treatment, at the completion of the treatment and any time the division requests a report.
Physician’s Report on Eye Injuries (WC-241) needs to be filled out in each case of eye injury resulting in any degree of permanent disability. This form will need to be forwarded to the employer or employer’s insurance company after treatment is rendered.
Physical Rehabilitation’s goal is to restore the injured worker, as quickly and as nearly as possible, to a condition of self-support and maintenance as an able-bodied worker, through physical rehabilitation. The physical rehabilitation program staff investigates and determines the employee’s eligibility to receive benefits. The program works closely with physicians, therapists, lawyers, insurers, and case managers. To be certified, each facility must meet criteria for certification of compliance to current professional standards.
All fees and charges under Missouri’s Workers’ Compensation Law per Section 287.140.3 RSMo “shall be fair and reasonable, shall be subject to regulation by the Division or the Commission, or the Board of Rehabilitation in rehabilitation cases. A healthcare provider shall not charge a fee for treatment and care which is. . .greater than the usual and customary fee the provider receives for the same treatment or services when the payor for such treatment or service is a private individual or a private health insurance carrier.”
Other than the healthcare provider selected by the injured worker at his or her expense, when the employee, employer or the employer’s insurance has notified the provider in writing of the injury being workers’ compensation related “no hospital, physician, or other health care provider. . .shall bill or attempt to collect any fee or any portion of a fee for services rendered to an employee due to a work-related injury.” Section 287.140.13(1) RSMo. If the injury is found to be non-compensable, the healthcare provider shall be entitled to pursue the employee for any unpaid portion/s of the fees or other charges for services provided to the employee.
If the hospital, physician, or other healthcare provider is having difficulties obtaining payments for services authorized in advance by the employer or employer’s insurance, they may want to file a Medical Fee Dispute.
Related: Medical Fee Disputes
In Missouri, it is fraudulent for a health care provider to use any of the following false billing practices:
- “Unbundling” an insurance claim by claiming a number of medical procedures were performed instead of a single comprehensive procedure;
- “Upcoding” a medical, hospital or rehabilitative insurance claim by claiming that a more serious or extensive procedure was performed than was actually performed:
- “Exploding” a medical, hospital or rehabilitative insurance claim by claiming a series of tests were performed on a single sample of blood, urine, or other bodily fluid, when actually the series of tests were part of one battery of tests; or
- “Duplicating” a medical, hospital or rehabilitative insurance claim made by a healthcare provider by resubmitting the claim through another healthcare provider in which the original healthcare provider has an ownership interest.
Any person in violation of the above referenced provisions is guilty of a class A misdemeanor and shall be liable to the state of Missouri for a fine up to twenty thousand dollars. Any person, who has previously pled guilty or has been found guilty of violating the provisions relating to the false billing practices and who subsequently violates the provisions of Section 287.129.1 RSMo is guilty of a class D felony.
The Missouri Department of Commerce and Insurance is responsible for over-seeing this portion of workers’ compensation law as it relates to a person who is engaging in or has engaged in any fraudulent workers' compensation insurance act under Section 287.129 RSMo., and may take action when they deem necessary. To file a complaint with the Missouri Department of Commerce and Insurance please visit their website.
Related: Report Workers' Compensation Fraud