Do You Know the Rule? Va. Payment for Health Care Services

Fredericksburg, VA (WorkersCompensation.com) -- In the Old Dominion, payment for health care services that an employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. But if there's an issue, the following rules apply.

Denials, etc.

If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer's workers' compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. The notification shall include the following information:

(1) The reasons for contesting or denying the itemization, or the reasons the itemization is considered incomplete;

(2) If the itemization is considered incomplete, all additional information required to make a decision; and

(3) The remedies available to the health care provider if the health care provider disagrees.

Payment or denial shall be made within 60 days after receipt from the health care provider of the information requested by the employer or employer's workers' compensation carrier for an incomplete claim under this subsection.

Get in the know in Virginia and the rest of the U.S. with Simply Research

Late Fees

Payment due for any properly documented health care services that are neither contested within the 45-day period nor paid within the 60-day period shall be increased by interest at the judgment rate of interest as retroactive to the date payment was due.

Liability to Employees Unaffected

An employer's liability to a health care provider shall not affect its liability to an employee.

Limitations on Recovery

No employer or workers' compensation carrier may seek recovery of a payment made to a health care provider for health care services rendered to a claimant, unless such recovery is sought less than one year from the date payment was made to the health care provider, except in cases of fraud. The Commission shall have jurisdiction over any disputes over recoveries.

Rules for Health Care Providers

No health care provider shall submit a claim to the commission contesting the sufficiency of payment for health care services rendered to a claimant unless:

(1) The claim is filed within one year of the date the last payment is received by the health care provider pursuant to this section; or

(2) if the employer denied or contested payment for any portion of the health care services, then, as to that service or portion thereof, such claim is filed within one year of the date the medical award covering such date of service for a specific item or treatment in question becomes final.

No health care provider shall submit, nor shall the Commission adjudicate, any claim to the Commission seeking additional payment for medical services rendered to a claimant before July 1, 2014, if the health care provider has previously accepted payment for the same medical services pursuant to the Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 901 et seq.

Share This Article: