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Legal Services

by Richard D. Weber, J.D.
MDA Legal Counsel
Published in the June 1993 issue of the Journal

Question: A patient of mine who works in a nursing home had an accident which required a core and crown. Since his employer was willing to file for worker's comp, my office was told I had to purchase a book that includes a schedule of fees, filing instructions and filing forms, at a price of $6.75.

I informed the administrator of the cost of the dental treatment and provided the procedure codes. I was told that the reimbursement would be quite a bit less than the cost of the treatment, and that the balance could not be charged back to the patient.

Since I did not sign any type of agreement with the worker's comp administrator, I feel I should not have to accept the reimbursement without charging the patient the balance. What it the answer?

Answer: Under the Worker's Compensation Health Care Services Rules, all providers of health care services, including dentists, are not permitted to balance bill a patient for the treatment of an injury or illness that is covered under Michigan's worker's compensation law. Under the rules, providers are reimbursed on the basis of the provider's usual and customary charge or the fee schedule amount, whichever is less. Providers may not charge or bill a patient for the difference between the actual cost of treatment and the maximum allowable payment established by the rules.

The rule against balance billing is, in effect, a condition of a provider's participation in the worker's compensation system. Consequently, reimbursement for providers who treat persons with worker's compensation coverage is limited to the maximum allowable payment established by the rules, even though the provider has not signed a written agreement with a worker's compensation carrier or administrator.

A publication entitled Worker's Compensation Health Care Services Rules is available from the Bureau of Worker's Disability Compensation for $6.75 per copy. It is advisable for providers who treat injured workers to obtain a copy because the book includes the fee schedules, filing instructions and filing forms. Copies may be obtained from:

Bureau of Worker's Disability Compensation
Health Care Services Division
P.O. Box 30016
Lansing, MI 48909

Checks should be made payable to "State of Michigan." When ordering the publication, providers can also request that their names be included on the Bureau's mailing list for future publication and updates of the rules.

Posted in: Billing Issues

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