A workers’ comp Explanation of Benefits (EOB) form is a document from the insurance carrier that details what medical treatments or wage-loss payments have been approved, adjusted, or denied on your claim — and why.
We get many frantic telephone calls and emails from people who have unpaid medical bills under workers’ comp. It is hard to assist these individuals because hiring a lawyer for a small amount of money is usually cost prohibitive. There is sticker shock when a hospital sends an unpaid medical bill for thousands of dollars for an ER visit. Here is some free advice about the fee schedule and explanation of benefits (EOB) form to help calm nerves.
Payment of medical bills under workers’ comp in Michigan
Workers’ comp guarantees payment of medical bills for employees who are hurt on-the-job regardless of their fault. All reasonable and necessary medical treatment should be covered 100%.
Included are ambulance rides, emergency room visits, hospital stays, doctors, prescription medication, durable medical equipment, physical therapy, and surgery. There should never be any copayments or deductibles owed for medical treatment under workers’ comp.
Choice of doctor under workers’ comp is your legal right
Employees have the right to select their own medical providers after 28 days from the start of medical care. We tell our clients to select the best possible doctor and make sure the insurance company pays the bills.
What is the explanation of benefits (EOB) form for workers’ comp in Michigan?
A workers’ comp explanation of benefits (EOB) form in Michigan is a document from the insurance carrier that details what medical treatments or wage-loss payments have been approved, adjusted, or denied — and why. State law requires medical providers accept payment based on a statewide fee schedule, commonly known as “cost containment.” All charges must be submitted on a proper claim form such as CMS 1500 or UB-92. The EOB shows how much was charged and approved for payment. If a medical provider is unhappy with the amount paid, they must contact the insurance company directly.
What’s on a workers’ comp explanation of benefits (EOB) form?
A workers’ comp explanation of benefits (EOB) form in Michigan typically includes the following information:
- Header Information: Your name, claim number, date of injury, and employer’s name
- Service Details: Date of treatment, medical provider, service codes, and procedure descriptions
- Billed Amount: The total charged by your doctor, hospital, or physical therapist
- Allowed Amount: The maximum the insurance company will pay under Michigan’s workers’ comp fee schedule
- Amount Paid: The actual amount paid directly to your medical provider
- Reason Codes: Alphanumeric codes explaining why a charge was adjusted, reduced, or denied
- Your Responsibility: In Michigan workers’ comp, you should owe nothing — no copayments, deductibles, or balance billing is permitted
Key things to watch for on your explanation of benefits (EOB) form
- Approved vs. Denied: Check whether the insurer accepted the treatment as work-related. If denied, the EOB must state a clear reason under Michigan agency rules.
- Billed Amount vs. Allowed Amount: A gap between these numbers is normal — Michigan’s fee schedule caps what insurers pay. You are not responsible for the difference.
- Balance Billing: Medical providers cannot bill you for amounts above what workers’ comp has paid. This is prohibited under Michigan law.
- Reason Codes: If a charge was reduced or denied, the reason code must be disclosed on the EOB along with what information is needed for additional payment.
- Unpaid Bills: If a bill goes unpaid for 30 days, the insurance company must receive notice of nonpayment by certified mail. A penalty of $50 or the bill amount (whichever is less) applies.
- Wage Loss vs. Medical EOBs: An EOB can cover both medical treatment and indemnity (wage replacement) payments. Review each one carefully to confirm the correct weekly comp rate is being applied.
- Michigan-Specific Rules: Michigan’s Workers’ Disability Compensation Agency governs payment timelines, fee schedules, and dispute resolution. Benefits are calculated at 80% of after-tax AWW with no copayments or deductibles owed.
Be aware of medical providers who want to double dip
Balance billing of the injured worker is not permitted. This is when a provider seeks additional payment from the injured worker above what has already been paid under workers’ comp.
Watch out for bureaucratic red tape at the insurance company
Watch out for insurance companies who file a dispute for no good reason and keep a lookout for the EOB forms. Agency rules say a clear reason for a payment adjustment and/or amount dispute must be disclosed. This information is supposed to be sent to the medical provider and injured worker on an EOB form along with what information is needed for additional payment.
What happens if medical bills are not paid and no explanation of benefits (EOB) form has been issued?
If medical bills go unpaid and no explanation of benefits (EOB) form has been issued, the insurance carrier may simply have let the bill slip through the cracks. It can be difficult getting their attention when an item has not been paid. Penalties apply to medical bills not paid within 30 days — the insurance company must receive notice of nonpayment by certified mail from the injured worker. The penalty is limited to $50 or the amount of the bill, whichever is less. While the penalty amount is small, it usually gets someone’s attention at the insurance company.
Injured on the job in Michigan and have questions about your explanation of benefits (EOB) form or medical bills? Contact our attorneys now for a free consultation!
If you have questions about your explanation of benefits (EOB) form or medical bills after being injured on the job, call now at (855) 221-2667 or fill out our contact form for a free consultation with an experienced lawyer. There is absolutely no cost or obligation. We’re here to help.
For more than 40 years, our lawyers have been helping people like you who have suffered from on-the-job injuries in Michigan. We understand the physical, emotional, and psychological hardships you are experiencing from your accident. We also have the skill, experience, and know-how to protect you and get you the best possible payout amount for your case.
To see what our own clients have to say about the caring, compassion, and communication they received from us, you can read in their own words about their experience here on our testimonials page from clients we have helped.
Michigan Workers Comp Lawyers never charges a fee to evaluate a potential case. Our law firm has represented injured and disabled workers exclusively for more than 40 years. Call (855) 221-2667 for a free consultation today.
Related information:
Workers’ Compensation Penalty Payment Explained
