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Workers Compensation Billing:  An Ounce of Prevention is Worth a Pound of Cure

During my many years of consulting chiropractic offices and working with their outstanding receivables, I found that most of my clients had something in common.  Many of their outstanding receivable accounts fell into the category of "Workers Compensation."  I also found that the reasons why my clients were experiencing problems collecting on their Workers' Compensation patients were very similar across the board.  The necessary initial investigative and research process that is required when treating a patient with a work-related injury was incomplete, sloppy or not performed at all.

A common trend that was most disturbing to me, as well as a nightmare to fix, was that many of these offices were gathering information for all possible insurances held by the patient (health, workers compensation) and submitting claims simultaneously to see "who would pay."  Another common problem I found, which resulted in many unpaid claims, was that the offices were documenting and diagnosing the work-related injury, but were filing the claims to the patient's health insurance, instead of gathering the information they needed to file the claims where they should have been filed - with the Workers' Compensation Insurance.  Upon receipt of the claims, the health insurance carrier would perform a "Coordination of Benefits" to determine who the responsible payer should be.  When the health insurance payer determined that the patient was being treated for a work-related injury (either from a report requested from the physician or the questionnaire sent to the patient), all claims were denied.

When handled properly from the very beginning, obtaining fair and complete reimbursement for a patient being treated for a work-related injury should be relatively easy to accomplish.  The "ounce of prevention" I refer to equates to diligence in the initial stage of fact-finding and information-gathering when a patient first presents due to a work-related injury as well as a routine to follow up on unpaid claims.

PHASE ONE:  FACT FINDING

Pursuant to the correct questions being asked upon a patient's first visit, it should be easily determined that the patient was injured at work.  Ideally, upon the patient's first visit, he/she has already completed an Accident Report (First Report of Injury), the employer is aware of the situation and a claim has been created with the Workers' Compensation Insurance.  If any of these 3 elements are missing, it is imperative to go back and make sure that they are completed.  It is possible to have a patient present as a result of a work-related injury where the employer has not been notified.  In a case such as this, the patient must immediately contact the employer and file an Accident Report, which in turn, the employer will then make contact with the Workers' Compensation Insurance.  Immediate action is required because, oftentimes, there are time limitations placed on the completion of the First Report of Injury.

Once all 3 elements are in place, you can move on to phase two.

PHASE TWO:  INFORMATION/DOCUMENTATION GATHERING

When all 3 elements have been covered, ideally, the patient will provide you with the Accident Report which contains all of the information you need to file your claims properly.  If the report does not contain insurance information, you will need to contact the employer to gather this information.

Let's assume that the report you are looking at only includes accident and employer information.  What information do you need to gather from the employer?

  • Name, Address, Telephone Number of Worker's Compensation Insurance
  • Date of Injury/Accident (if not present on report)
  • Claim Number Assigned to Case
  • Name of Adjuster Handling the Claim (employer might not have this information)

PHASE THREE:  MAKE CONTACT WITH WORKERS' COMPENSATION ADJUSTER HANDLING THE CLAIM

You may think that contacting the adjuster who will be handling the claim is overkill, but in my opinion, it is vital.  It doesn't hurt to verify the information you have received and it certainly doesn't hurt to begin a rapport with the person who will be approving and sending payment for the claims you are submitting.  Oftentimes, the address of the Workers Compensation Insurance provided by the employer may not be the address you should file your claims too.  By speaking to the adjuster handling the claim, you can obtain the information you need to properly file your claims for an expedited response.

If the employer has supplied you with the Workers Compensation information, call them with the patient's name, claim number or social security number and the date of the accident/injury.  Obtain the name and telephone number of the adjuster.  Give the adjuster a call and verify the claims mailing address, claim number and date of accident/injury and ask them if there is any information they can provide you that would help in the expedition of claims handling.  The claim number should always be referenced on any and all claims submitted.  And, addressing the claims directly to the claims adjuster can also speed up the process of claims handling, i.e....

Joe G. Adjuster
Cincinnati Insurance Company
P.O. Box 123
Cincinnati, OH  45229

CLAIM FOLLOW UP

Workers' Compensation Claims, just like health insurance claims, need to be followed up on, and periodically, it may become necessary to contact the insurance adjuster to determine the status of unpaid, submitted claims.  Calling on these types of claims should be part of your routine.  There are state laws and insurance guidelines that Workers' Compensation payers must adhere to.  Don't assume that a delay of response or payment on Workers' Compensation claims should be expected just because you are dealing with "Work Comp."  Get in touch and get answers.  You don't want to find out 3 months down the road that payment has been delayed because...    a report hasn't been received....    The patient failed to complete a questionnaire....     A new adjuster has been assigned to the claim, etc. etc.

CONCLUSION

Following these few basic steps (an ounce of prevention) can and will alleviate problems and poor receivables that are very likely to occur if these steps are ignored.  Save yourself from possible labor intensive resolutions and possible claim denials by spending a little time in the initial fact finding and information gathering phases of filing Workers' Compensation claims.


UNDERSTANDING WORKERS' COMPENSATION

This article was written in order to address basic, common problems and resolutions to the initial handling of workers' compensation claims in order to effectuate prompt adjudication of these types of claims.  Be advised that types of workers compensation coverage can vary and that insurance guidelines, laws and limitations can vary state to state. 

Medical Billing Course.com has recently released a course entitled "Understanding Workers' Compensation Insurance."  If you would like more information, please visit www.medicalbillingcourse.com.

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Article submitted by Tammy Harlan of Medical Billing Course.com.   Copyright 2008, Medical Billing Course, LLC