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This summary sets forth various workers' compensation regulations regarding outpatient physical therapy services. The Workers' Compensation State Regulations resource may serve as a tool to assist in locating regulations. Please send database comments and corrections to advocacy@apta.org.
To the extent an individual or entity wishes to rely upon information contained in this resource, such reliance should be based upon an independent legal review and analysis of applicable law. This resource was prepared for informational purposes only and is not offered or intended, nor should it be relied upon, for legal advice for any specific set of circumstances. Additional legal doctrines, federal and state statutes, and case law not set forth herein may apply to your situation and such laws, rules and regulations can vary from state to state. You should consult with your own attorney to obtain specific legal advice on your particular facts and circumstances and applicable laws, rules, and regulations.
Key Resources/Links
Agency:
Department of Labor & Industry, Bureau of Workers' Compensation
Contact Information:
BWC Phone 717/783-5421
E-mail Pennsylvania BWC
News & Updates:
Publications (Scroll down to "Newsletters")
See BWC home page for Announcements
Other:
Medical Cost Containment Rules (See: Title 34, Part VIII, Chapter 127)
Fee Schedule
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | Not reported | Generally, since January 1, 1995, medical fees for outpatient services rendered under the Act are capped at 113% of the Medicare reimbursement rate. Payment rates are then frozen and thereafter updated annually by the percentage change in the Statewide average weekly wage. 34 Pa. Code §§ 127.101(a) and 127.153. | https://www.dli.pa.gov/Businesses/Compensation/WC/HCSR/MedFeeReview/Fee%20Schedule/Pages/Part%20B/Part-B-Fee-Schedules.aspx |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | Capped at 113% of the Medicare reimbursement rate applicable. For services rendered after January 1, 1995, medical fees shall be updated only in accordance with §§ 127.151 -- 127.162 (relating to medical fee updates). | https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Pages/WC%20Act/PA-Workers-Comp-Rules--Regs-Chapter-127.aspx |
| Are there limits on the number of physical therapy visits allowed? | No | Subject to utilization review per § Chapter 127, subchapter C UR--General Requirements | http://www.portal.state.pa.us/portal/server.pt?open=514&objID=553022&mode=2 |
| Are there limits on payment per visit for outpatient therapy services? | No | ||
| Do regulations require use of treatment guidelines? | No | Subject to utilization review per § Chapter 127, subchapter C UR--General Requirements | https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Pages/WC%20Act/PA-Workers-Comp-Rules--Regs-Chapter-127.aspx |
| Is a referral required in order to see a physical therapist? | No | At discretion of carrier | |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | With respect to outpatient care, the regulations provide: "If a Medicare allowance does not exist for a reported HCPCS code, or successor codes, the provider shall be paid either 80 percent of the usual and customary charge, or the actual charge, whichever is lower." 34 Pa. Code § 127.103(c). |
Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
| Can the injured worker be charged for any claim-related services? | No | Balance billing prohibited per § 127.211 | https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Pages/WC%20Act/PA-Workers-Comp-Rules--Regs-Chapter-127.aspx |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | ||
| Are there provider network and/or managed care regulations in place? | Yes | Statute provides for coordinated care organizations: Title 77 | https://www.dli.pa.gov/Businesses/Compensation/WC/HCSR/Pages/Physicians-List-Defined.aspx http://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter9/chap9toc.html&d=reduce |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | § 127.129. Out-of-State medical treatment: for providers outside PA, not licensed by Commonwealth, capped at Medicare rate for Harrisburg, PA | https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Pages/WC%20Act/PA-Workers-Comp-Rules--Regs-Chapter-127.aspx |
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | No |
1 While some states use a mandatory fee schedule, many states have provisions for fees to be negotiated above or below the published fee schedule. "Yes + / - " indicates that fees can be negotiated above or below the fee schedule. "Yes -" indicates that fees can only be negotiated below the fee schedule.
The following payer types conduct business in this state.
Private Carriers - Yes
Self-insured Employers or Groups - Yes
Competitive State Fund - Yes
Exclusive State Fund - No
State Comp Fund (last resort) - No