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If you fall off a ladder at work and suffer a compound fracture, you’ll probably be more worried about the bone sticking out of your leg than who’s going to pay the hospital bill.
But if payment does cross your mind, relax. Workers compensation likely will pay for that trip to the emergency room.
The real worry comes in if you have to make return visits to the ER.
That’s where things can get complicated, and worker’s comp might not pay those bills. Let’s deal with some common questions injured workers have:
Does Workers Comp Pay for Emergency Room Visits?
Workers comp almost always covers the initial visit to the emergency room. Rules vary from state-to-state, but return visits might not qualify for coverage. A worker will typically need to prove their condition worsened and required immediate treatment.
But first things first.
A trip to an emergency room is, by definition, an emergency. The worker doesn’t have the time or inclination to formally notify their employer and get the proper forms filled out. They just want to get to the hospital.
About 25% of injured workers get their initial treatment at an ER. Those visits don’t require pre-authorization because the case hasn’t even been filed.
If possible, the injured worker should tell the hospital staff that they have a work-related injury. Workers comp deadlines vary by state, but workers generally have 30 days to notify their employer of the accident.
The employer is then obligated to submit a claim to their workers comp insurance company.
That will cause their rates to increase or perhaps trigger an investigation into safety-rules violations. That’s why some employers are tempted to try to keep the ER visit off the books. They might tell you to just forward them the bills and they’ll pay them.
Don’t do it.
There’s no guarantee they’ll live up their word, and you’ll want to have the injury properly filed in case it turns into a long-term health issue that keeps you out of work for even five days or longer.
Follow up to make sure your employer has submitted your case to its insurance company. If not, contact your state’s workers’ compensation department.
Can You Go to the ER While on Workers Comp?
If your claim is approved and you need ongoing treatment, you will have to choose from a list of “approved providers” if you want the bills paid. (Note: you aren’t legally bound to go to a doctor from that list. But visits to non-approved doctors will not be covered by workers comp insurance).
Injured workers typically have about a month to pick an approved provider, and they must use someone on that list for at least 90 days. The precise time limits vary depending on the state.
Approved providers can’t always provide for patients 24-7. Your condition could worsen during the night or on a weekend, and an ER might be your only treatment option.
If possible, contact your authorized medical provider first. They might send you to a specific ER, which might make paying the bill less of a hassle. And a hassle it can be.
The insurance company will want proof that an ER visit was necessary, and that you couldn’t wait until an approved provider was available. That might require testimony from the ER doctor, and even that might be tricky.
ER doctors see an assembly line of broken bodies and don’t have regular patients. Remembering precise details of a person’s visit can be difficult. You should do everything possible to ensure detailed and precise records are taken of your treatment and that you get copies of those records.
What Happens If the Claim Is Disputed?
A trip to the ER isn’t usually a one-bill experience. You might get a variety of separate charges from various hospital departments, labs and physicians.
Keep copies of the bills and send the originals to the workers comp insurance company. Do it via certified mail, just to make sure there is a record of the case.
If they dispute the claim, you should immediately contact your state’s workers’ comp agency and file a “petition for benefits” or “application for mediation.” The phraseology differs from state-to-state, but basically you are appealing the ruling and setting up a showdown in front of a mediator or judge.
As with any showdown, you want to go in well-armed. That means having detailed records of your ER visit, testimony from doctors and a knowledge of how the appeals process works.
That also means you might want a workers comp lawyer. The insurance company will certainly have one, and there could be a lot of money at stake. You have already taken an unwanted trip to the emergency room. The last thing you need is to be taken to the cleaners.
