When talking workers’ compensation (WC) billing and collections, it’s best to keep your high beams on. After all, compared to their commercial payer counterparts, these entities don’t always follow the same rules of the road. So, to help you stay in your lane when it comes to creating and submitting workers’ comp claims, here are a few important considerations:
1. Always verify the patient’s eligibility before providing any treatment.
First things first: When a patient attends therapy as part of a work injury-recovery program, it’s important to establish where and how the incident occurred. As this resource from AAPC mentions, patients may not always divulge the deets of their injuries. And if a patient neglects to tell you a particular injury was work-related, your biller may end up sending that patient’s claims to his or her primary insurance. If that happens, it’s up to you to return any reimbursement to the insurer and rebill the workers’ comp payer. Additionally, as the APTA advises in this FAQ, “You need to verify the name of the adjuster, claim number, date of injury, and the body part that relates to the claim. Many carriers require that the ‘approved diagnosis’ is included on your claims. Make sure the therapist knows what the approved diagnosis is.”
2. Know your state’s guidelines.
As in many other areas of practice, the guidelines for billing for workers’ compensation claims vary from state to state. While it may seem like a lot of work, getting familiar with your state’s workers’ compensation laws will not only ensure better, faster reimbursement, but also keep you out of legal hot water. That said, no matter where you’re located, you’re always beholden to HIPAA regulations. So, make sure you strictly adhere to all privacy rules—and never bill a patient’s employer for the treatment of non-work-related injuries and illnesses.
3. Obtain a hard copy of the authorization from the adjuster.
When you speak with the adjuster, it’s crucial that you verify—and obtain proof of—the treatment authorization. And just as importantly, do not accept verbal authorization. Why? Because if the payer tries to deny your claims for lack of authorization, it’s a whole lot harder to appeal if you can’t provide written confirmation that the visits were, in fact, authorized.
Also, as you chat with the adjuster, find out whether he or she is part of a payer network. If so, then you’ll know where to send your claims, which will help you avoid the common—and time-consuming—mistake of sending claims directly to the payer instead of the network.
4. Track authorized visits.
Speaking of authorizations, make sure you’re keeping a close eye on how many authorized visits you’ve used. Typically, authorizations have visit and date restrictions. That means if you’ve reached the end date of the authorization, the payer may deny any claims for future dates of service—even if the patient hasn’t used up all of his or her authorized visits. If you’re coming up on the end date—but the patient requires additional treatment—contact the adjuster ASAP before the authorization expires.
5. Attach any required documentation to your claims right away.
As WebPT’s Charlotte Bohnett mentions in this post, “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.”
Also, some WC payers may require you to submit patient documentation with the claim. If that’s the case, make sure you’re proactive about attaching the appropriate documentation. Otherwise, you’ll likely have to wait several weeks to receive payment for that session.
6. Be cautious when billing for work hardening.
Despite being a common treatment for workers’ comp patients, work hardening can be tricky when it comes to proper coding. When billing for work hardening (or work conditioning), there are two codes a provider or coder can choose from:
- 97545: work hardening/conditioning; initial 2 hours
- 97546: work hardening/conditioning; each additional hour
As the above-cited resource from the APTA states, “97546 cannot be utilized alone without 97545. [Additionally], if only one hour of care is provided, then it could be argued that you are not at the level of a work hardening/conditioning program. In that case, codes 97110 or 97530 might be appropriate.” In other words, payers expect that work hardening treatment will last at least two hours. If it does not, then the provider or biller may want to consider using a different code.
Here are some other considerations for work hardening:
- Use of 97545 may or may not imply direct, one-on-one contact.
- Some fee schedules may have local codes for work hardening/work conditioning, so always check your regional fee schedule and payment rules to verify the appropriate CPT codes.
7. Do not attempt to collect an unpaid workers’ comp claim amount from the patient.
According to the APTA, in every state (excluding Illinois) providers cannot legally balance a bill for unpaid workers' compensation claims. That’s because workers’ comp is intended to protect the patient, and therefore, patients are not liable for the cost of treatment. If you run into issues with balancing the bill, you should contact your state’s workers' compensation commission as soon as possible, as they can help resolve the issue.
8. When in doubt, contact your state’s workers’ compensation commission.
As mentioned in the section above, every state has a workers’ compensation commision that can answer questions and guide you on next steps whenever you hit a bump in the WC road—whether you need to balance unpaid workers' compensation claims or obtain interpreter services. Additionally, the Workers' Compensation Research Institute (WCRI) has two publications that make it easy to compare the various workers’ compensation laws among states: Managed Care and Medical Cost Containment in Workers' Compensation: A National Inventory and Benchmarks for Designing Workers' Compensation Medical Fee Schedules. You can also find additional information on workers’ comp laws on the US Department of Labor website.
So, there you have it: eight tips to help you navigate the twisty-turny terrain of workers’ compensation claims. Got any tips for ensuring your WC claims get paid? Let us know in the comment section below!