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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 of incurring the expenses.
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.
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.
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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