eNotes: Workers’ Compensation – June 2024 – Virginia

June 19, 2024

VIRGINIA LEGISLATIVE UPDATE

Amendment to Statute Addressing Claims by Healthcare Providers for Payment of Medical Bills Eliminates Date Exception to Application of One-Year Limitations Provision

Va. Code Ann. § 65.2-605.1 (enacted March 28, 2024, Effective July 1, 2024) Prompt payment; limitation on claims.

  1. Payment for health care services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided.
  2. If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer’s workers’ compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. The notification shall include the following information:
  3. The reasons for contesting or denying the itemization, or the reasons the itemization is considered incomplete;
  4. If the itemization is considered incomplete, all additional information required to make a decision; and
  5. The remedies available to the health care provider if the health care provider disagrees.

Payment or denial shall be made within 60 days after receipt from the health care provider of the information requested by the employer or employer’s workers’ compensation carrier for an incomplete claim under this subsection.

  1. Payment due for any properly documented health care services that are neither contested within the 45-day period nor paid within the 60-day period, as required by this section, shall be increased by interest at the judgment rate of interest as provided in § 6.2-302 retroactive to the date payment was due under this section.
  2. An employer’s liability to a health care provider under this section shall not affect its liability to an employee.
  3. No employer or workers’ compensation carrier may seek recovery of a payment made to a health care provider for health care services rendered to a claimant, unless such recovery is sought less than one year from the date payment was made to the health care provider, except in cases of fraud. The Commission shall have jurisdiction over any disputes over recoveries.
  4. No health care provider shall submit a claim to the Commission contesting the sufficiency of payment for health care services rendered to a claimant unless (i) such claim is filed within one year of the date the last payment is received by the health care provider pursuant to this section or (ii) if the employer denied or contested payment for any portion of the health care services, then, as to that service or portion thereof, such claim is filed within one year of the date the medical award covering such date of service for a specific item or treatment in question becomes final.
  5. No health care provider shall submit, nor shall the Commission adjudicate, any claim to the Commission seeking additional payment for medical services rendered to a claimant before July 1, 2014, if the health care provider has previously accepted payment for the same medical services pursuant to the Longshore and Harbor Workers’ Compensation Act, 33 U.S.C. § 901et seq.
  6. The Commission, by January 1, 2016, shall establish a schedule pursuant to which employers, employers’ workers’ compensation insurance carriers, and providers of workers’ compensation medical services shall be required, by a date determined by the Commission that is no earlier than July 1, 2016, and no later than December 31, 2018, to adopt and implement infrastructure under which (i) providers of workers’ compensation medical services (providers) shall submit their billing, claims, case management, health records, and all supporting documentation electronically to employers or employers’ workers’ compensation insurance carriers, as applicable (payers) and (ii) payers shall return actual payment, claim status, and remittance information electronically to providers that submit their billing and required supporting documentation electronically. The Commission shall establish standards and methods for such electronic submissions and transactions that are consistent with International Association of Industrial Accident Boards and Commission Medical Billing and Payment guidelines. The Commission shall determine the date by which payers and providers shall be required to adopt and implement the infrastructure, which determinations shall be based on the volume and complexity of workers’ compensation cases in which the payer or provider is involved, the resources of the payer or provider, and such other criteria as the Commission determines to be appropriate.

TAKEAWAY:  Prior version of statute indicated that the One-Year Limitation to file a claim did not apply to Medical Treatment rendered prior to July 1, 2014. The 2024 Amendment makes it so that One-Year Limitation applies to all claims for payment of medical expenses, even those for expenses incurred prior to July 1, 2014.  The application of this statute is retroactive.

Employer’s Letter to Claimant denying benefits must include language notifying Employee of the right to dispute the claim denial.

Va. Code Ann. § 65.2-601.3. (Effective July 1, 2024) Notice of right to dispute claim.

  1. If an employer subject to this title, or an employer’s insurer, denies a covered employee’s request for workers’ compensation benefits, the employer or the insurer, as applicable, shall include in its letter denying benefits a notice that the employee has a right to dispute the claim denial through the Virginia Workers’ Compensation Commission. Such notice shall include the following text: EMPLOYEE RIGHT TO DISPUTE DENIAL OF WORKERS’ COMPENSATION BENEFITS.  IF YOU DISAGREE WITH THIS DENIAL, YOU HAVE THE RIGHT TO DISPUTE THE DECISION BY FILING A REQUEST FOR A HEARING WITH THE VIRGINIA WORKERS’ COMPENSATION COMMISSION. IT IS YOUR RESPONSIBILITY TO DISPUTE THE DECISION AS SOON AS PRACTICABLE. THE WORKERS’ COMPENSATION COMMISSION IS A STATE AGENCY RESPONSIBLE FOR MAKING FINAL DECISIONS ON DISPUTED WORKERS’ COMPENSATION CLAIMS. HOWEVER, SUCH CLAIM MAY BE LOST IF YOU DO NOT FILE IT WITHIN THE TIME LIMIT PROVIDED BY LAW, WHICH IS TYPICALLY TWO YEARS AFTER THE INJURY.

Such notice shall also include the address, telephone number, and website through which the employee may contact the Virginia Workers’ Compensation Commission.

  1. Failure to comply with the provisions of this section shall not be considered a failure to make a required report for the purposes of § 65.2-902.

TAKEAWAY:   The new notice provision will require claims handlers to revise the language of denial letters as set forth by the statute. There is no indication in the statute as to the penalty for non-compliance with this provision; however it specifically states that violation of this provision is not intended to result in a civil penalty for failure to file an Employer’s Injury report.

Any questions regarding this legislation can be addressed to Jamie L. DeSisto at (443)641-0558 or jdesisto@tthlaw.com.