How Do Worker’s Compensation Fee Schedule’s Work?
When you are injured on the job, you may be entitled to collect certain benefits from workers’ compensation. In Florida, employers who have more than four employees are required to carry workers’ compensation insurance. Any employer who hires construction workers is required to carry coverage for all employees, even if there are fewer than four. Other employers may not need to carry coverage, but in general, most employers must do so.
One of the challenges many workers complain about is the difficulty of purchasing prescription medications at a pharmacy of their choice. That is because Section 440.13 (3)(j), Florida Statutes a pharmacy need not participate in the Workers’ Compensation program that requires them to abide by a fee schedule. Learn more from the experienced workers’ compensation attorneys at Sibley Dolman Gipe Accident Injury Lawyers, PA Accident Injury Lawyers.
What Is a Workers’ Compensation Fee Schedule?
This is a tool individual states use, and it tells providers the maximum amount they can charge for a service when they are dealing with individuals covered under workers’ compensation insurance. While there is a broader manual for this, most states, including Florida, have their own fee schedule.
The schedule explicitly defines the maximum amount a provider may charge for all procedures related to the injured person’s treatment. While a provider may charge less than the amount offered, they can only charge a larger amount when they can provide proof the additional costs are justified.
Most Common Workplace Injuries
According to the National Safety Council (NSC) the three top injuries suffered on the job are:
- Overexertion – In general, this can be caused by constantly having to pick up heavy items on the job or engaging in a repetitive task. This can mean workers who are working on computers all day long and have repetitive stress injuries, such as carpal tunnel syndrome, are classified as overexertion. Workers who are in an environment that requires them to constantly bend to pick up packages or boxes would fall into this category as well. More than one-third of all workplace injuries occur in this category.
- Contact with objects and equipment – These victims can suffer serious injuries to their backs, head, or limbs. More than one-quarter of all workers’ compensation claims happen as a result of being struck by a piece of equipment, or against a piece. While this may sound obtuse, think about bending over and picking up something on the floor and striking your head against a table when you stand up. This type of injury can happen in an industrial setting, but the victim hits their head on a piece of large equipment. Other types of injuries included in this category are crushing injuries where a victim has something fall on them, or when they are forced against a wall or other unmovable surface because of a forklift error. Slightly more than one-quarter of all workplace injuries are in this category.
- Slips, trips and falls – These accidents can occur anywhere on a job site. Whether a victim falls from a ladder, a scaffolding, trips over misplaced tools or work-site supplies, or falls down a flight of stairs. Nearly 27 percent of all workplace accidents are as a result of slips, trips, and falls. These types of accidents cause a variety of injuries from minor contusions to head injuries and victims could require several weeks or months of medical care and treatment.
As you can judge from the most common workplace injuries, victims often must see multiple doctors, undergo rehabilitation treatment, and are likely to lose time from work. In the case of a workers’ compensation claim, those who are treating victims must be aware of the fee schedules. In addition, a doctor cannot simply refer a patient off to another specialist without first getting approval for the referral. This makes the entire process cumbersome and as a victim, you may find yourself frustrated with the process.
In addition to the restrictions of referrals, doctors who are treating victims who are injured in the job can only bill a specific amount for the injuries. Let’s look at some of the potential injuries and the reimbursement policies for each.
Reimbursement Policies Under Workers’ Compensation Fee Schedules
Before you can determine the extent of an injury you suffer on the job, you will require an evaluation by a physician. According to Florida Health Price Finder, you will go through multiple steps as follows:
- Evaluation by physician – On average, this visit will cost about $77
- X-ray examination – On average, x-rays on the back will cost $69
- Six visits with a chiropractor – You can estimate this will cost about $197
- One steroid injection – Should this be required for pain, the cost will be $2,567
- Physical therapy – To help you recover from a back injury $467
As you can see, these procedures assume your back injury does not require surgery. This also means the total cost of these basic care needs will be approximately $3,377. However, reimbursement via the workers’ compensation fee schedules will likely be far less than this, because doctors who are treating victims of workplace injuries have agreed to do so based on specific costs set down by the state.
Before being reimbursed for expenses, a doctor must use a complex schedule that includes each individual component of your treatment. As you can see from the Florida Workers’ Compensation Fee Schedule manual, there are more than 200 pages of codes that doctors must adhere to.
Each individual service, including the use of an anesthesiologist, nurse practitioner, and use of equipment like braces has a “cap” on the amount the doctor may charge for their services. Additionally, these doctors agree to work with patients knowing they must adhere to the schedule. As a victim of a workplace accident, you have few options when it comes to which doctor to see, although you can request one change per cycle.
Fighting Back Against Insurance Companies
When you are injured on the job, the last thing you are probably thinking about is the amount a doctor is going to be reimbursed for their services. What you should be aware of however is that you do not have to make a copayment on any treatments you receive. Because of the complex rules that surround workers’ compensation treatments, the carrier who holds your employer’s insurance is responsible for all your medical expenses.
These expenses may include:
- Emergency care – If you are rushed to the hospital via ambulance and seen in an emergency room, this care is fully reimbursed. However, once you have been admitted, the hospital may have to transfer your care to a doctor other than your personal care physician for treatment.
- Tests and X-rays – Depending on your injuries, the doctor may have to order specific tests like MRIs or x-rays. These tests must be preapproved by the insurance carrier and the amount the facility will be reimbursed will vary depending on the type of test, the county in which your treatment occurs, and the reason for the test.
- Pain control meds – If you are prescribed pain control medications for a back injury, you may face challenges picking up your meds at your preferred pharmacy. Some pharmacies do not cover workers’ compensation insurance prescriptions. Additionally, per the guidelines set out by the Department of Labor (DOL) and using the Florida workers’ compensation fee schedule, the doctor may be limited as to what drugs may be prescribed.
- Physical therapy – If your treatment regimen includes physical therapy the reimbursement to the therapist will be far lower than normal reimbursements under most private or state-offered insurance policies. To submit payments under the Workers’ Compensation fee schedule the company would have to first get approvals to offer the therapy, then they are mandated to accept the fees paid under the WC policy.
- Surgical procedures – If you suffer an injury that requires surgical intervention, doctors are going to have to break down each component of your bill when dealing with Workers’ Compensation. Under the fee schedule, they will have to break out the anesthesia, cost of the operating room, cost of the room in a medical/surgical unit, doctors’ costs, the cost of nursing care, etc. Again, keep in mind, the final bill submitted for reimbursement by your case team could take a considerable amount of time.
The fee schedule is complicated, and this is one reason why you must keep track of each procedure and each doctor’s visit. You may be frustrated with the amount of information that you are being inundated with, and that is understandable. This is one of the reasons why you may wish to consider speaking with an experienced workers’ compensation attorney immediately following a workplace injury.
Use Caution if You Are Offered a Workers’ Compensation Settlement
You may think if you are offered a sizable settlement that you should quickly accept it. Be very careful: Once you accept an offer under Workers’ Compensation, you will be on your own for any medical expenses that are incurred once that offer has been accepted. In fact, an insurance company may make an offer in the hopes of minimizing the costs they are paying out for your medical bills. While the chances are very high they are paying less than “standard” fees for your treatment from a work-related injury, they are also aware that long-term treatment is going to cost them even more.
Remember, when you are in a car accident or other type of accident, chances are the insurance company is going to pay full medical bills, regardless of the amount. In fact, in most cases you will use your personal insurance, which means you decide which doctor to see, where you purchase your prescription medications, and your doctor will determine the course of treatment to make sure you make as full a recovery as possible. With workers’ compensation claims, all medical bills, prescription drugs, and treatments must be approved before your treatment commences, which could slow down your recovery.
Confused About Workers’ Compensation? Do Not Give Up
If all of this information leaves you confused, do not worry. Insurance companies are hoping you ARE confused, because that means they can limit their exposure if you do not know what questions to ask, or what your rights are. Because most people do not know what questions to ask, or what rights they have under workers’ compensation rules, they are liable to agree to things they would not agree to under “normal” circumstances.
There are likely many factors of a workers’ compensation claim you are unfamiliar with, and that is fully understandable. This is why after you have reported your injury to your employer, you should seek out guidance from an experienced lawyer who understands Florida workers’ compensation laws. Whether your claim has been denied, a doctor has told you they wish to provide a specific service that has been denied, or you have been informed your benefits are going to expire, it’s important to speak with an attorney to make sure you have someone advocating on your behalf.
Remember, workers’ compensation insurance companies have a team of attorneys to help them justify their actions, particularly when they are denying claims, or determining the victim is no longer eligible for benefits. You should expect the best level of care, regardless of what the insurance company is requiring from the doctor. Just because the doctors are limited to how they charge for treatment under the Florida Workers’ Compensation fee schedule does not mean you should suffer the repercussions in your treatment.
Seek an Experienced Florida Worker’s Compensation Attorney
You have rights when you are injured at work, and you want to make sure your expenses are covered. Regardless of what type of injury or illness you have as a result of being on the job, you are entitled to the best possible care to ensure you recover fully, and if possible, return to your job. Do not let the barriers stop you—instead, contact a workers’ compensation attorney and let them guide you through this difficult process. A Florida workers’ compensation lawyer can answer your questions, make sure you can pay for the medical care you deserve, and help you negotiate an appropriate settlement if required.
Sibley Dolman Gipe Accident Injury Lawyers, PA offers free consultations to those that have suffered injuries at work and are having trouble seeking compensation for the damages they suffered as a result. To contact Sibley Dolman Gipe Accident Injury Lawyers, PA about a consultation on your case you can either call our Clearwater office at (727) 451-6900 or fill out a contact form online.