Understanding Billing for Worker's Compensation

Understanding Billing for Worker's Compensation

As an alternative to the emergency room, your medical practice facility can be a local employer’s best friend when injuries happen on the job. Unfortunately, billing Workers’ Compensation Insurance can be a headache for you if you do not gather the right information from the beginning and follow the proper steps throughout the payment process. Therefore, if you are going to add workers compensation to your occupational medicine program, you must understand how to bill the insurance.


Step 1: Train Your Front Desk Staff

From the moment an injured worker shows up at your medical practice clinic, your front desk receptionist should go into “workers’ comp mode.” Unlike personal insurance, where a patient brings in an insurance card to cover treatment costs, injured workers should bring in a claim number given to them by their employer before they arrive at your clinic for treatment. The employer must call their workers’ compensation insurance company directly and report the injury in order to get the claim number from their adjuster for the employee. When the injured worker checks in, it is crucial your receptionist collects required identification and verifies all of the worker’s demographics. In order to submit your claim for the patient’s visit, your receptionist must also collect:


1. Name, address, and telephone number of the employer

2. Date the worker’s injury occurred

3. Name of employers’ workers’ compensation insurance company

4. Name of the claim adjuster

5. The claim number


There may be times when a patient arrives at your clinic with a work-related injury and they have not yet notified their employer. Should this happen, your receptionist should immediately ask the patient to contact their employer to file an accident report. In turn, the employer should contact their workers’ compensation insurance company to obtain a claim number. It is important this happens immediately, as limitations dictate the time in which the First Report of Injury can be completed. In either situation, once your receptionist has gathered the information from the employee, they should contact the workers’ compensation insurance company directly to obtain the name, telephone number, and address of the adjuster. Then, they should call the adjuster to verify the claim’s mailing address, the claim number, the date of accident/injury, and the type of injury the patient has. Failure to verify the type of injury with the adjuster can slow down, or completely stop, your payment, especially if a patient comes in presenting a different injury than what was reported to their employer originally. Additionally, some adjusters may provide codes approved for billing a particular visit. Any codes given should be shared by the front desk staff with the provider rendering treatment and the coders on your billing team. Before ending the phone call, the adjuster should also be asked to give any additional information that could expedite the claims process.


Step 2: Proper Charting

Once the workers' compensation insurance has been verified, the patient is ready to be seen by the provider. It is important providers understand and complete all workers compensation paperwork properly and accurately chart the visit during, or immediately following, the patient’s visit.


Step 3: Claim Submission

The third step in receiving payment for workers compensation injuries is submitting a claim for payment. All claims must be submitted to workers’ compensation insurance companies within 95 days from the date of service and must include the claim number. Additionally, the coder must use any codes given by the adjuster on the claim forms in the first priority boxes. In some cases, the provider will add additional codes to go along with the patient’s injury and diagnosis. These codes are allowed, so long as the provider gives supporting documentation. The additional codes should be listed following the prior approved codes from the adjuster. All claims should be submitted with medical records for the date of service, including office notes, labs, and x-rays supporting the injury.


Step 4: Claim Follow-Up

After submitting claims, your biller should follow up on the claim’s status. Any claims not processed within 30 days will require a call to the insurance adjuster to determine their status. You should never assume a delay in payment is because workers’ compensation insurance companies are known for slower payment turnaround times. Workers’ compensation payers are required to adhere to state laws and insurance guidelines for payment. On follow-up calls, you may often learn payments have not been sent for reasons as common as:


1. A report was not received

2. The patient failed to complete a questionnaire

3. A new adjuster has been assigned to the claim

4. Your claim never made it to the payer


In addition to doing follow-up calls, it is good practice for your workers’ compensation biller to build a rapport with the adjusters at the workers’ compensation insurance companies. A good rapport with an adjuster can help expedite payment on your claims. Understanding workers' compensation insurance, and following the proper steps to submit accurate claims, can turn the headache of dealing with injured workers into another successful day at your medical practice clinic.


Candice Smith-Riles