Workers’ Compensation Explanation of Benefits (EOB)

Workers’ Compensation Explanation of Benefits (EOB)
Date: February 10, 2023

Keeping those Health Insurance Explanations of Benefits forms can be helpful to your work injury attorney

Whether it’s via email, text, or regular mail, we have all received documentation from insurance companies detailing payments made for medical treatment. These payments are documented on what is commonly referred to as an explanation of benefits or “EOB” forms. Typically, medical providers agree to accept payment of a reduced percentage of the face amount of the bill by an insurance carrier in return for being part of the accepted network of medical providers whom the insurance carrier will agree to pay. Typical insurance carriers include private healthcare plans, liability insurance carriers, or workers’ compensation insurance carriers. In Pennsylvania worker’s compensation cases, the law only requires the worker’s compensation carrier to pay a reduced percentage of the face amount of medical bills, hospital bills, prescription bills, etc. These reductions are addressed in the Medical Cost Containment Regulations of the Pennsylvania Code. Generally, medical fees are capped at 113% of the amount Medicare would pay for the same or similar services. If a Medicare allowance does not exist for the medical service, then the provider is paid 80% of the usual and customary charge for the service. Payments for prescription drugs are limited to 110% of the average wholesale price of the product.

Contact a Pennsylvania Work Injury Lawyer at DLP Law

If you’ve suffered a work injury and have questions about your worker’s compensation claim, contact me at tcummings@dlplaw.com or call (570) 347-1011 for a free consultation.

Disclaimer: The above article is for instructive purposes only and each case is fact sensitive. Consultation with an attorney should be obtained instead of reliance upon the legal issues discussed in this column.

Tom Cummings
Thomas P. Cummings has been a Partner with Dougherty Leventhal & Price, LLP since 1996 and has been with the firm since 1991. He focuses his practice on workers’ compensation, Social Security Disability and personal injury cases.