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Insurers Should Be Required to Send EOBs to Injured Workers and Their Counsel
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In Pennsylvania workers’ compensation proceedings, administrative fairness and transparency are crucial to ensuring that injured workers receive their entitled benefits promptly and their access to effective representation is preserved. Under the Pennsylvania Code (Pa. Code), insurers must give healthcare providers a written Explanation of Benefits (EOB) detailing exactly how medical bills are paid. This compels insurers to justify their payment decisions to those providers.
This said, the Pa. Code does not require insurers to disclose the same to injured workers and their representatives. Consequently, injured workers are often uninformed regarding insurers’ payments for their medical care, undermining their ability to obtain the guidance needed to protect their rights. Compounding this issue, after a Workers’ Compensation Judge’s decision, their counsel often receives unlabeled checks for payment of medical bills and counsel fees. This results in unnecessary time spent by counsel determining what each payment represents, whether providers were fully paid, and whether counsel’s fee was correctly deducted in accordance with the decision.
In ordinary healthcare interactions outside the workers’ compensation system, patients receive EOBs and can advocate for themselves. Therefore, within the system, Workers’ Compensation Judges (WCJs) and claimants’ counsel should require this same transparency to foster clarity, streamline dispute resolution, and minimize unnecessary litigation. As insurers already generate EOBs for providers to comply with their legal obligations, there is no good reason not to provide them promptly to an injured worker and their representative.
Currently, Insurers Must Send EOBs to Healthcare Providers Only
Per 34 Pa. Code § 127.209, when an injured worker’s medical treatment is covered by workers’ compensation insurance, the insurer must give the treating provider a written EOB. The EOB must describe the calculation of payment, noting any code changes and the rationale. If the bill is denied entirely, the EOB must explain the denial. In all cases, the EOB must inform providers that they are barred from billing the employee for any difference between the provider’s charge and the insurer’s payment.
This practice ensures that providers understand how and why payments were adjusted, while also protecting injured workers from surprise billing. However, Section 127.209 remains silent on whether the injured worker and their counsel are entitled to comparable disclosures.
Why Injured Workers and Their Counsel Should Receive EOBs
There are several reasons insurers should provide EOBs to injured workers and their counsel for every medical bill they pay.
First, EOBs ensure better health outcomes. Too often, counsel discovers well after the fact that an injured worker has delayed or discontinued medical treatment due to a lack of knowledge as to how or when their medical bills are being processed. This not only may cause a lapse in necessary medical care, which hinders the recovery process, but it may also trigger serious mental health consequences for the injured worker.
Receiving EOBs provides peace of mind for the injured worker that the workers’ compensation system is functioning smoothly and that their medical bills are being paid. It also allows their representative to effectively counsel them and take immediate legal action when necessary.
Second, EOBs provide clarity, which helps injured workers make informed decisions about their care. EOBs explain what treatments have been paid, partially paid, or denied. If an injured worker promptly receives this information, they can coordinate with their providers to adjust treatment plans or seek alternative therapies that are covered, secure pre-approvals for necessary care, or resort to secondary insurance to cover urgent care. Without this knowledge, injured workers may unknowingly continue with uncovered treatments or be left without proper guidance on available options.
Third, EOBs help injured workers prevent complications by detecting coverage gaps. Some treatment denials or reduced payments occur due to administrative issues such as incorrect billing codes, missing documentation, or insurer misunderstandings. If an injured worker’s representative receives these notices in real time, they can investigate the issues and work to resolve them with the medical provider or the insurer before they disrupt recovery. This proactive approach keeps care on track and minimizes long-term disability risks.
Fourth, EOBs enable injured workers’ representatives to advocate more effectively and efficiently for their rights. Workers’ compensation attorneys are advisors to injured workers, steering their claims through a complex system. Giving the attorney seamless access to EOBs allows them to act quickly and strategically ensure their clients’ rights are preserved without unnecessary steps or litigation.
When disputes require litigation, EOBs provide counsel with thorough documentation of the insurer’s decision-making. This is critical for demonstrating patterns of payment denial or establishing that the insurer’s reason is without foundation. By giving counsel the same access as providers, disputes can be resolved faster, hearings can be shorter, and unnecessary filings can be avoided. This not only benefits the injured worker but also reduces the strain on WCJs and the overall workers’ compensation system.
Finally, EOBs allow courts and injured workers’ counsel to efficiently and accurately calculate attorney fees. Section 442 of the Pa. Workers’ Compensation Act, along with the Pa. Commonwealth Court’s decision in Neves v. Workers’ Compensation Appeal Board (American Airlines), 232 A.2d 996, makes timely EOB delivery to injured workers and their counsel even more critical.
Section 442 states that “all counsel fees, agreed upon by claimant and his attorneys, for services performed in matters before any workers’ compensation judge or the board . . . shall be approved by the workers’ compensation judge or board as the case may be, providing the counsel fees do not exceed twenty per centum of the amount awarded.”
In Neves, the court held that a 20% contingency-fee agreement between a claimant and counsel applies not only to indemnity benefits but also to medical compensation and is per se reasonable. Thus, judges need not assess reasonableness based on the complexity or effort of legal work. Neves realigns interests among injured workers, attorneys, and medical providers by ensuring counsel can be fairly compensated for pursuing medical benefits. The dissent in Neves noted that Section 442 “evidences a legislative intent to protect claimants against unreasonable fees imposed upon them by their attorneys pursuant to improvident fee agreements.” The holding in Neves encourages attorneys to continue seeking full healthcare entitlements for their injured worker clients, and encourages providers to willingly render treatment, confident that they will receive payment for that treatment.
Thus, timely EOB delivery to injured workers’ counsel is essential in carrying out the legislative intent of Section 442 by allowing transparent review of an attorney’s fee calculations. Both injured workers and their counsel benefit from transparent, direct access to the insurer’s rationale as reflected in EOBs.
Through 34 Pa. Code § 127.209, healthcare providers receive documentation that helps them understand and challenge insurers’ payments. Workers’ compensation attorneys will benefit from this same transparency. Unlabeled checks with no accompanying detail of what the payments represent make it difficult, if not impossible, for WCJs and attorneys to determine the total payments made to providers and whether the insurer complied with Section 442 regarding counsel fees.
Pa. law and WCJs should require insurers to send EOBs to injured workers and their counsel
Pennsylvania’s current requirement that insurers supply EOBs to healthcare providers is a vital transparency safeguard, but it stops short of complete procedural fairness. When an injured worker and their representative do not have direct access to insurers’ EOBs, they lack critical insight into insurers’ decision-making, which hinders advocacy and creates inefficiencies.
Extending 34 Pa. Code § 127.209 to injured workers and their representatives will promote transparency, empower representation, reduce disputes, and improve judicial efficiency. It imposes a minuscule administrative burden on insurers as they have already created the EOB—a burden that is outweighed by the system-wide benefits of broader dissemination of EOBs.
If insurers have nothing to conceal and are acting in good faith, there should be no barrier or delay in providing this documentation directly to injured workers and their counsel. Doing so aligns with the fundamental principles of fairness and reasoned adjudication in workers’ compensation cases, and helps WCJs fairly and efficiently administer justice in those cases.
Kajal Alemo is Partner and the Chair of Workers’ Compensation Operations at Pond Lehocky Giordano Inc., the largest workers’ compensation and social security disability law firm in Pennsylvania, and one of the largest in the U.S. She can be reached at kalemo@pondlehocky.com.
Reprinted with permission from the November 10, 2025 edition of The Legal Intelligencer © 2025 ALM Media Properties, LLC. All rights reserved. Further duplication without permission is prohibited, contact 877-257-3382 or reprints@alm.com.
