Workers’ compensation collections can seem like a stress-induced migraine for providers. Between special terminologies, unique collection forms, and legal obstacles, many practices don’t have the resources or know-how to properly bill a worker injury case.
So PYP is here to ease your worries and provide some simple steps to improve your returns on workers’ comp claims.
Learning the Basics
Because it’s actually a legal process with a medical delivery component, workers’ comp can be very confusing. Knowing a few background guidelines can significantly help you along the way.
“The workers’ comp world has always been somewhat problematic for practices and physicians. There are a lot of things being done right now to help resolve those issues,” said Don St. Jacques, Senior Vice President at Jopari Solutions, Inc., a medical billing firm specializing in workers’ compensation and property casualty claims.
Workers’ comp provides coverage for wage replacement benefits, medical treatment, vocational rehabilitation, and other benefits to employees who are injured on the job or contract an occupational disease.
According to St. Jacques, it equals 2-3% of all medical spending and represents 100 million billing transactions a year. That’s no small potatoes.
Group Health vs. Workers’ Comp
It’s important to note that while the policyholder is usually the patient in the group health world, the employer is the subscriber in the workers’ comp sector.
Also, what has normally termed an explanation of benefits (EOB) in a patient-insured claim is an explanation of review (EOR) in a workers’ comp case. And instead of identifying a claim through your regular healthcare identification number, you use a case file or claim number in its place.
Let your staff know that there is no deductible or copayment linked to workers’ compensation claims. Providers must accept the compensation payment as paid in full because billing the injured worker for any outstanding balance is illegal.
Nuts and Bolts of Billing
Billing for workers’ compensation claims varies from state to state. Knowing your state’s guidelines will keep your practice in compliance and allow for better payments.
Always keep in mind that HIPAA privacy rules must be followed at all times, so be careful never to bill illness and injuries unrelated to a worker’s compensation claim to an employer.
If a patient comes in to treat an injury but doesn’t mention that it occurred at work, your practice might go ahead and bill his or her primary insurance. However, when the patient later requests that his or her employer’s insurance be charged for the medical services, it is your practice’s responsibility to re-bill the workers’ comp insurance and return the original reimbursement to the primary payer.
It’s also important to fill out the proper forms when billing for workers’ compensation. These forms include the First Report of Injury Form and CMS-1500 claim form.
The doctor should complete the First Report of Injury Form when the patient first seeks treatment for a work-related illness or injury. This form differs by state.
The billing department will then need to attach a CMS-1500 claim form to the physician’s documentation in order for the workers’ compensation insurance to properly remit payment. Make sure to include the date of injury on the CMS-1500 as it is often overlooked.
“It’s absolutely critical when the information is delivered to payers that it contains not only the substantiation of the charges but also all of the other findings and results,” said St. Jacques. “Those two things combined will drive the reimbursing and disposition of the patient.”
Follow these simple steps and you should see an increase in workers’ compensation payments. Although it can be a bit problematic, there is no reason why your practice should be eating workers’ comp costs.
Have you encountered problems with workers’ comp or other special claims? Let us know your situation and maybe we can feature your problem in our next article.