Is it legal for hospitals to bill or ask for a medical insurance for a work related injury?

Question

For some reason I thought if you had a work related injury, hospitals had to bill the workers comp and it was illegal for them to bill any private medical insurance. I know auto insurance has a cap, like $100,000 personal injury and once that runs out the medical insurance starts being billed but for some reason I thought it was different with work comp claims. Was I wrong?

Answer 1

Just fyi Mbrcatz, not all states w/c pays at the Medicare level. As a matter of fact, the state of Michigan pays higher than Medicare.

A hospital is not supposed to bill a person's private medical insurance unless the claim has been denied by the employer and/or the employer's w/c carrier.

As a medical biller for a group of ER physicians, we have many people come in a say the reason they are there is work related and later we find out it is not and the claim is denied. If the hospital got the person's medical insurance, it saves us from having to rely on the person to contact us later and give it to us.

Bottom line, it is not illegal for them to obtain the information for back-up purposes.

Answer 2

No, workers comp does NOT EVER pre-approve payments. So you go to the hospital, you get treated, either you or the hospital or the employer sends the bill to the workers comp carrier, and IF they decide it's covered, then they pay at the medicare rate, and the hospital isn't allowed to bill you any co pay or deductible or anything.

But if they DON'T cover, for whatever reason, then YOU pay the bill, either you or the hospital submits it to your health insurance carrier, and YOU pay the co pays and deductibles.

So of course hospitals want the private medical information - what if your employer let the comp policy lapse? What if the comp carrier decides it's not work related, and doesn't pay? Then the hospital would be stuck holding the bag.

Answer 3

There's one very good reason why Hospitals should always get a person's health insurance information, even if it appears the stay will be covered under workers comp: if the WC carrier denies to pay because it disputes the causality of the injury to the treatment, the Hospital cannot be reimbursed by your insurer unless it obtained pre-authorization for the hospitalization or surgery; nor can it be reimbursed if it failed to follow other procedures required by its contract with your insurer.

So this is perfectly legal; the Hospital just cannot bill WC, get paid in full, then bill your insurer as if it wasn't a WC-covered injury -- that would definately be insurance fraud.

I hope this helps.

Answer 4

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