Jeffrey P. Gale, P.A. // Dealing With Medical Payments Made by the Wrong Entity During a Pending Florida Workers’ Compensation Case

It is not unusual for entities other than the workers’ compensation insurance carrier to pay medical expenses following a work-related accident. The most common payors are health insurance carriers, Medicare, and Medicaid. (PIP (a/k/a “No Fault”) insurance also pays if the accident involves motor vehicles, but since their rights are different than those of the other entities mentioned above for purposes of this blog, PIP will not be addressed in this blog.)

Since workers’ compensation is supposed to be the primary payor — PIP can add a wrinkle to this concept. See section 627.736(4), Florida Statutes — the other entities are entitled to reimbursement for the payments they have made. How the reimbursement is made depends on when, during the life of the workers’ compensation case, the payment is made. If it is made post-settlement, the payment is typically made as part of a negotiated agreement between the entities and the injured worker’s attorney. This is always the situation when the workers’ compensation employer/carrier denies responsibility for the accident and injuries throughout the entire case. Alternatively, when the carrier has accepted compensability of the claim it may agree as part of the negotiated workers’ compensation settlement to satisfy the liens. In this circumstance, hold harmless language should be included in the settlement agreement to protect the claimant in case the carrier fails to be proactive in resolving the liens and the entities come after the claimant for repayment.

While the workers’ compensation case is ongoing, we always make a claim against the workers’ compensation carrier to be responsible for the medical bills paid by the other entities. If the workers’ compensation carrier agrees to be responsible, it should coordinate with the medical providers to have them repay the funds they have received from the other entities. Once the reimbursements are made, the workers’ compensation carrier will pay the medical providers in accordance with the Florida Workers’ Compensation Fee Schedule.

This convoluted procedure makes sense. Workers’ compensation medical bills are supposed to be paid per the Fee Schedule. The amount may be more or less than what the other entities have paid. It is much easier if the medical providers simply repay what has been paid, then accept from the workers’ compensation carrier the amounts due under the Fee Schedule.

Once the workers’ compensation carrier has agreed to pay the medical providers, we have yet to be put into a situation of having to pursue a legal remedy to enforce the agreement. One way we protect ourselves from getting into this situation is by obtaining proof before closing the case that the medical providers have been paid. This is done by requesting a printout of the workers’ compensation benefits paid.

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