In Wisconsin workers compensation medical treatment is unlimited for an injured workers medical, surgical, chiropractic, psychological, podiatric, dental, and hospital treatment “as may be reasonably required to cure and relieve from the effects of the injury.” Wis. Stat. § 102.42(1). If the workers comp insurance company denies paying for medical treatment, usually saying through an independent medical examiner (IME), that the treatment is not work-related, then the injured employee must prove the treatment is necessary by expert medical testimony. Wisconsin Tel. Co. v. Industrial Comm’n, 263 Wis. 380 (1953).
In addition, the workers comp insurance carrier is responsible for reasonable and necessary treatment “to prevent further deterioration in the condition of the employee or to maintain the existing status of such condition whether or not healing is completed.” Wis. Stat. § 102.42(1). Liability for medical treatment goes from the date of injury or the last payment of indemnity to the applicable statute of limitation in Wis. Stats. Sec. 102.17, either 6 or 12 years for most injuries but the exact time limitation must be checked individually for each case. Liability for future medical expenses can be extinguished by a full and final compromise approved by the department. Schenkoski v. LIRC, 203 Wis. 2d 109 (Ct. App. 1996).
If medical expenses are paid by your health insurance company, it probably has a worker’s compensation exclusion and subrogation clause, meaning it has to be paid back either after a successful hearing or out of a settlement. See Wis. Stat. Sec. 102.30(7)(a).
If the health insurer paid the medical bills pursuant to a contract with the provider under which certain charges are written off or “adjusted.” the workers comp department LIRC has held that these adjusted amounts are not reimbursable to the medical provider. Hoefs v. Midway Hotel/Paytons Rest., WC Claim No. 1999-029146 (LIRC Oct. 21, 2003) . But see Monson v. Heyde Health Sys., Inc., WC Claim No. 2005-009475 (LIRC June 18, 2008) holding that written-off charges were reimbursable to medical provider even though provider wrote off amounts as uncollectible because employee was uninsured. If possible, we try to get the workers comp carrier to hold the injured worker harmless from any “balance billing” but this is not always possible.
Pharmacists are required to substitute a generic under Wisconsin workers compensation medical treatment for a prescribed brand-name drug if the generic drug is therapeutically equivalent as determined by the federal Food and Drug Administration, and costs less than the prescribed brand-name drug. The injured worker may insist on the brand-name drug but then be responsible for the difference in price. Wis. Stat. § 102.425(2)(c).
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