Disclaimer: This article is for educational purposes only and does not constitute legal advice. Always consult a qualified attorney or claims administrator for guidance specific to your situation.
Detailed Answer
When you receive medical treatment related to a workplace injury, your employer’s workers’ compensation insurer (claims administrator) is responsible for paying approved medical bills directly to the health care provider. To confirm payments were applied correctly, follow these steps:
- Obtain Your Explanation of Benefits (EOB):
An EOB is a statement from the claims administrator that outlines which medical expenses were approved, denied, or adjusted. You should receive an EOB after each medical bill is processed. Review it to see the billed amount, the approved amount, and any patient responsibility.
- Request a Payment Ledger from the Insurer:
Under Massachusetts law, medical providers and injured workers may ask the insurer for a detailed ledger showing all payments made under the claim. This ledger tracks each invoice, the payment date, and the payment amount. You can request this in writing or via email from the claims administrator.
- Check with Your Medical Provider:
Contact your doctor’s billing office or hospital. Ask them to run your account history and verify receipt of payments from the workers’ compensation insurer. If there’s a balance showing as unpaid despite insurer records, this may signal a misapplied payment.
- Review Statutory Timelines:
Under Massachusetts General Laws c.152 §13A, a claims administrator must pay or deny medical bills within 45 days of receipt. If 45 days have passed without action, you may formally notify the insurer in writing to comply.
- Resolve Discrepancies:
If you or your provider believe a payment was missed or misapplied, send a written request for clarification to the claims administrator. Include copies of the original bills, EOBs, and any payment ledgers. Keep records of all correspondence.
- Escalate if Necessary:
If the insurer does not respond or correct errors within a reasonable time, you may file a complaint with the Massachusetts Department of Industrial Accidents (DIA). Visit the DIA website for forms and instructions: Massachusetts DIA.
Helpful Hints
- Keep a dedicated folder (digital or paper) for all EOBs, invoices, and payment notices.
- Note dates of all communications with your insurer and provider.
- Confirm whether your employer’s group health plan has any interest under c.152 §11A for cost recovery.
- Ask your provider to resend bills directly to the claims administrator using the correct claim number.
- Consider involving a workers’ compensation attorney if repeated errors occur.