Why You Should Read This
If you were hurt on the job in Pennsylvania, you’ve probably been told:
“You have to see the company doctor for 90 days.”
“If you see anyone else, workers’ comp won’t pay.”
“Just wait until the adjuster approves that MRI.”
Much of this is flat out wrong. By the end of this article, you will know:
- Exactly when—and when not—Pennsylvania’s “90 Day Rule” applies
- How one slip up by your employer can give you immediate freedom to choose your own doctor
- Seven delay games insurers use to slash care and payments—and how to beat them
- Why independent specialists and caution with diagnostic centers matter- to both your health and your settlement
- Concrete action stepsto protect your claim, your wages, and your recovery
- Where to get help right now if you live in Eastern PA!
1 | The 90 Day Rule—Real, but Easy to Defeat
Pennsylvania law lets employers create a panel of at least six health care providers (three must be physicians). If the panel meets every technical requirement and you were properly notified, you must treat with one of those providers for the first 90 days of care.
Most employers miss at least one requirement—often more. A single defect voids the rule immediately and you can pick any doctor you want (and the workers’ comp carrier must still pay).
Fast myth buster:Because so many employers miss one of these steps, lawyers often call the “company doctor for 90 days” rule a myth. Always ask for (1) the posted list and (2) both signed acknowledgments. If either is missing, you’re free!
After Day 90
Even when the list is valid, once 90 days pass you may treat anywhere. Simply notify your employer within five days of the first visit to your new doctor and keep a copy for your records.
Built in Exceptions
- Emergencies: Go to the nearest ER. The carrier must pay.
- Second surgical opinions: You may choose any surgeon for that consult; the carrier pays.
- Specialties not on the list: If no dermatologist, neurologist, etc. is listed, you may pick your own immediately.
2 | How Insurers Stack the Deck With “Friendly” Doctors
Even a fully legal panel can be lopsided. Carriers prefer occupational clinics known for cost containment and quick return to work releases. Diagnostic testing orders often funnel into imaging centers whose owners also read the scans. That built in conflict can tilt MRI reports toward “mild age related changes” instead of genuine ligament tears.
Local Example: Monroeville Imaging on Rodi Road and Highfield Open imaging.
Attorneys and doctors in Western Pennsylvania frequently complain that MRI reports from these facilities downplay serious injuries like ACL tears and herniated discs. If you are injured at work, almost every payor forces you to go to these facilities where they have an MRI that is old, cheap, and the radiology reports that are often incomplete or under reported.
Tip: If you’re scheduled for imaging at these facilities, politely request an independent hospital based radiology group instead. UPMC, AHN, or Independence Health.
3 | Seven Delay & Under Payment Tactics (and How to Beat Them)
1. “We never got that bill.”
Carriers must pay complete bills within 30 days. Send bills certified mail or e fax with confirmation pages. If the excuse repeats, as it often does, your doctor should file a Fee Review petition.
2. “Duplicate submission—denied.”
A stall to restart the 30 day clock. Resubmit once with proof, then go Fee Review. Interest accrues from day 31.
3. Partial code payments.
The adjuster pays the office visit but “forgets” the x ray fee or “inadvertently changes” the fee—hoping nobody notices. Rigorous bill audits plus Fee Review reclaim these dollars.
4. “Silent PPO” discounts.
Bills pass through an unapproved network that chops another 10 20 percent off the regulated fee. Providers should contest every unexplained “network” reduction; legislation is pending to outlaw the practice.
5. “Peer review says your therapy isn’t necessary.”
Pennsylvania requires a formal Utilization Review if reasonableness/necessity is disputed. An internal insurer letter is not enough. Demand UR or file a Penalty Petition. Have an attorney help.
6. “Not related to accepted injury.”
The carrier accepts “low back sprain” but refuses MRI bills for lumbar radiculopathy. Courts have penalized this tactic; the carrier must petition a judge if it truly believes the condition is unrelated. When other problems arise, such as hip pain on the opposite side from being non-weightbearing, have your attorney add the problem to the claim!
7. Chronic late checks.
Repeated 35 or 40 day payments may warrant penalties up to 50 percent of the overdue amount. Detailed payment logs help your lawyer prove the pattern.
4 | Penalty Petitions: Your Equalizer
A Penalty Petition lets the judge sanction insurers for:
- Late or partial payments
- Failure to issue required forms
- Non payment of related medical bills
- Ignoring Utilization Review procedures
Judges often award 10 percent of the unpaid amount for routine violations and up to 50 percent if the conduct looks willful. Insurers usually settle quickly once penalty exposure and attorney fees mount.
5 | Protecting Yourself (and Your Case)
- Demand documentation. Get the panel list and both signed acknowledgments.
- Keep meticulous records. Note every call, fax, e mail, and mailing. Take pictures of your injured limb (bruising, wounds, swelling, etc.)
- Question conflicts. Ask if the imaging center has a contract with the insurance and how often the insurance sends patients there.
- Get second reads. A neutral musculoskeletal radiologist can overturn a “soft” MRI interpretation.
- Call an attorney early. Consults are free, and lawyers earn only if they improve your benefits.
- Choose independent physicians. Doctors outside carrier controlled clinics have zero incentive to rush you back before you’re ready.
6 | Why Independent Medicine Matters
At Prisk Orthopaedics and Wellness in Monroeville, Board Certified orthopaedic surgeon Dr. Victor Prisk treats work injuries from foot to shoulder to neck and back- without pressure from employers or insurers. We:
- Order high resolution imaging at facilities with fellowship trained MSK radiologists
- Provide detailed, evidence based disability notes to protect wage benefits
- Defend treatment plans through Utilization Review with peer reviewed literature
- Track billing, fee reviews, and penalty exposure so insurers pay promptly and fairly
If a “company clinic” minimizes an ACL tear or downplays hand nerve damage, a genuine second opinion can change your treatment—and your settlement value—overnight. Don’t wait 90 days if your employer botched the panel notice.
7 | Call to Action
Injured at work? Confused about the 90 day rule? Frustrated by endless insurer delays?
→ Schedule a confidential appointment with Dr. Prisk today.
Visit orthoandwellness.com or call (412) 525-7692. We’ll audit your employer’s panel compliance, craft a treatment plan focused on your recovery, and team up with your attorney to keep the insurer honest.
Better health, bigger settlements, fewer headaches—start with an independent opinion.
References
- Pennsylvania Workers’ Compensation Act, 77 P.S. § 531 et seq.
- Pennsylvania Department of Labor & Industry, “Employer Information—Designated Health Care Provider List Requirements.”
- Wolf, Baldwin & Associates, P.C., “Medical Treatment Under the Pennsylvania Workers’ Compensation Act.”
- Daniel J. Siegel, Esq., “The Myth of the 90 Day Rule,” Pennsylvania Bar Association Workers’ Compensation Section Newsletter (2009).
- Cardamone Law, “What Is the PA Workers’ Comp 90 Day Rule?” (blog post).
- Testimony of Charles Artz, Esq., on House Bill 1141 (Silent PPO discounts), PA House Labor & Industry Committee (2016).
- Zweifel v. Myers, 2020 Ohio 3414 (Ohio Ct. App. 2020).
- Miller v. Purcell et al., Lycoming Cty. Ct. C.P., No. 05 02126 (Pa. 2006).
- Pennsylvania Bureau of Workers’ Compensation, “Medical Fee Review & Utilization Review” Procedures Manual (2024).
- Cipriani & Werner, P.C., “Penalties in Pennsylvania Workers’ Compensation Claims” (practice note, 2023).
