What is the Workers’ Compensation 90-Day Rule?

The 90-day rule in Pennsylvania workers’ compensation cases limits the doctors injured workers can visit within the first 90 days after their injury if they want their employer’s insurance to cover it. Officially, this rule is known as Section 306(f.1)(1)(i) of the Pennsylvania Workers’ Compensation Act.

How does the 90-day rule work? First, for the rule to come into play, your employer must have a list, known as a “panel list”, of designated healthcare providers that meets specific criteria. In order for the 90-day panel list provision to apply, the employer must be able to produce an acknowledgement of the panel list, signed by the injured worker, at the time the worker was hired, and again as soon as possible after the date of the work injury. If the employer cannot produce both of these acknowledgements signed by the injured worker, the injured worked does not need to treat with anyone on the panel list. Second, if you want workers’ compensation insurance to cover your treatment within the first 90 days, you must receive treatment from a healthcare provider on this list.

However, it’s important to note that the 90-day rule doesn’t apply to emergency medical treatment. Furthermore, you can still choose to see a different healthcare provider during this period, but you may end up paying out-of-pocket if you do so. After the first 90 days, you’re free to seek treatment from any doctor you want, and workers’ compensation will cover the cost, provided that the treatment is reasonable and necessary.

Designated Healthcare Providers

What criteria must a designated healthcare provider list meet to be valid? There are four key items:

• There must be at least six healthcare providers on the list.
• No more than four of the healthcare providers can be coordinated care organizations.
• At least three of the healthcare providers must be physicians.
• If your employer employs, owns, or controls any healthcare providers on the list, they must disclose that information.

Even if the designated healthcare provider list meets these criteria, there are still some situations where injured employees can avoid the 90-day rule:

• If the employer does not make this list available to injured employees, the 90-day rule will not apply.
• If none of the healthcare providers have locations within a reasonable distance, the injured worker may be able to choose other providers.
• If none of the healthcare providers have the specialty service the injured worker requires, they may be able to choose other providers.

Second Opinions and Surgeries

The 90-day rule also includes a partial exception for second opinions regarding invasive procedures, like surgeries. If a provider from the employer’s designated list recommends an invasive procedure, the injured worker can seek a second opinion from any healthcare provider they choose.

However, suppose the second healthcare provider gives a differing opinion on treatment, and the injured worker wants to pursue that treatment option. In that case, they must still receive their chosen treatment from one of the providers on their employer’s list as long as it happens within 90 days of the second opinion.

Workers’ Compensation Attorney Serving Pennsylvania

Have you been injured on the job in Pennsylvania? Are you unsure if your employer’s designated healthcare provider list is valid? Contact Stine & Associates, P.C., for a free consultation of your case.

One of our experienced workers’ compensation attorneys will evaluate your case, check if your employer’s healthcare provider list is valid, and explain your legal options.