Billing in itself is tricky and a lot to manage. Toss in workers’ compensation (WC) claims and the plot only thickens. Thankfully, there are steps you can take to ensure your WC claims not only get paid, but get paid quickly.

But, first, a definition: According to the American Association of Professional Coders (AAPC), “Workers’ compensation provides coverage for wage replacement benefits, medical treatment, vocational rehabilitation, and other benefits to workers who are injured at work or acquire an occupational disease.”

1.) Verify and authorize.

Like I explained in my patient verification blog post, you should always verify insurance benefits eligibility before the patient arrives for his or her appointment. The same applies for WC. In fact, it’s particularly important for WC, because—as the AAPC explains—if a patient fails to specify that the injury or disease is work-related, then the practice will bill the primary insurance. But the patient won’t want that and will request that you bill his or her WC carrier instead. And then the practice runs into a giant mess of resubmissions and possible refunds, denials, and appeals.  

So, find out whether the patient’s injury falls under WC; then verify the claim number, adjuster, injury type and the body part to which it relates, and the date of the injury. From there, contact the adjuster. You’ll need to verify benefits, determine if the WC is part of a network (which can affect where you’ll submit your claims, thus affecting timely processing and reimbursement), and obtain an authorization. Regarding authorizations:

  • Obtain a hard copy of the authorization. It’s hard to appeal denied claims if you only ever get a verbal authorization.
  • Track your authorized visits. WC will deny claims if the visit count or dates of service fall outside of the conditions specified in the authorization.

2.) Include approved diagnosis and documentation.

Many WC carriers require providers to include the approved diagnosis on their claims. So, first, make sure your therapists know the approved diagnosis, and second, make sure it is on the claim. Another common WC requirement? Documentation. Be sure to attach patient notes to the claim.

3.) Keep cases separate.

As the AAPC notes, “Sometimes a patient will present to the provider for a workers’ compensation injury and also wish to be seen for a reason unrelated to the employment injury.” Keep these encounters separate, and document them as separate cases.

4.) Follow the rules.

  • Never bill to the employer because that violates HIPAA privacy rules.
  • Know the federal and state regulations regarding workers’ compensation.
  • Use the correct forms. According to the AAPC, these include “the First Report of Injury Form and the CMS-1500 claim form.” The provider will complete the First Report of Injury Form when the patient first seeks treatment for a work-related illness or injury. The biller or billing service will then submit the CMS-1500 claim form (plus documentation) to the workers’ compensation insurance for reimbursement. “The date of injury always needs to be completed on the CMS-1500 and can often be overlooked by billing,” the AAPC cautions.
  • Accept WC payment as payment in full according to your state’s approved fee schedule. There is no deductible or copayment, and “balance billing of [the] patient is prohibited,” the AAPC says.

Got any WC pro tips? Share them in the comments below.

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