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Section 13 - Medical Benefits

Massachusetts Section 13 Workers Compensation Medical Benefits

If you’ve been hurt on the job, your employer’s Workers Compensation insurance company is responsible for paying for any of the medical bills that are related to your injury and are medically necessary. While that seems easy, nothing in life ever is. If you’ve been trying to schedule a medical appointment regarding a workers comp case, you know that it’s not as simple as calling the doctor and getting an appointment. You need claim numbers, approvals, and utilization review. The reason, in part, is because of Section 13 of the Massachusetts Workers Compensation Statute.

How Much Does My Doctor Get Paid?

The first problem some injured workers have is getting doctors who accept Workers Compensation patients. In part, that’s due to the fact that doctors receive much lower fees when they treat workers compensation patients. Section 13 sets the rates that doctors receive. These “board rates” are set by the Executive Office of Health and Human Services. However, a different rate may be agreed on by the insurer, employer, and health care provider.

This part of the Workers Compensation Statute also sets up a scheme where medical providers are given oversight in their treatment of injured workers. The statute wants to keep costs down for insurers employers while also ensuring that medical providers are being paid enough that they routinely accept Workers Compensation patients.

What If My Doctor Doesn’t Accept Board Rates?

In reality, Section 13 does limit the maximum that the insurance company will have to pay for a certain procedure. Unfortunately, not all doctors will do the procedure at those rates. But, even insurance companies sometimes understand that the cheapest doctor is not always the best doctor.

If the insurance company agrees that a surgery or other procedure is medically necessary, it will want the procedure to be done well. That’s because if the surgery goes badly or is botched, then it increases the amount the insurance company will have to pay for wage benefits and additional medical treatment. So, if there is a highly recommended doctor that will perform the surgery for the injured worker, the insurance company might agree to pay the doctor more than the board rates to ensure that a competent doctor does it.

What If My Doctor is Out of State?

The insurance company is only responsible for paying board rates, no matter where the surgery is performed. Luckily, Massachusetts truly has a world-class set of doctors and hospitals. Even so, sometimes injured workers seek treatment out of state due for convenience or for many circumstances. That can create a conflict when the out-of-state doctor or hospital is not used to treating Massachusetts Workers Compensation patients.

In these situations, the insurance company will often negotiate in good faith with the doctor to get the treatment approved. However, there will often be a limit to how much the insurance company is willing to pay, and the injured worker might be left with having to find a different doctor or medical facility.

Experienced Workers Compensation Lawyers

Getting medical treatment can be complicated. At Marcotte Law Firm, our Workers Compensation Lawyers use our decades of experience to ensure that injured workers don’t get lost in the shuffle and that they can get to see their doctors as quickly as possible.

If you’ve been injured on the job and are having problems with medical treatment, call the experienced Workers Compensation Attorneys at Marcotte Law Firm for a free, no obligation consultation.

Client Reviews
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Mr. Marcotte and his staff are courteous and respectful, I've known Mr. Marcotte for over 25 years and I recommend him and his colleagues as the best lawyers in Lowell and Massachusetts area . God Bless them all. Minerva Martinez
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