Get Your Workers Comp Medical Coding and Billing Right

History of workers’ compensation is basically the oldest social insurance program that is in existence, it really first started in Europe in the 1800s but it was quite common in the US in the early 1900s. Read this expert medical coding training article for more.

Wisconsin is a state actually had the first workers' compensation insurance program in 1911. And by 1949, all states had some form of a workers' comp system. Truly, workers' compensation insurance or workers' comp coverage is really that legal compromise.

If you think about it, it's kind of that scales of justice where we're balancing out that compromise between the worker and their employer as the businesses. So in order to encourage the businesses to accept the responsibility for the premiums because our employers, your employers, my employers pay for the premiums for those who work comp insurance premiums.

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So in order for businesses to accept that responsibility, workers gave up the right to sue the employer for damages resulting from a job related injury. So on the other side of the scale, in order to compensate employees who required medical treatment who missed work due to workplace injury, employer avoids potential costly lawsuits.

So we really get that balancing for the most part. Injured workers receive medical care and disability income irrespective of fault as per healthcare regulations. There are some exceptions to that but for the most part.

The employer is really truly protected from that catastrophic lost of, you know, because they have that stated amount of benefits for the injury so forth. So if we were to have an unfortunate death of an employee, you know, they're working construction and they have a death of employee, really the workers' comp is what protects that employer from having a catastrophic lawsuit.

So in essence, it's truly a no fault system. The injured employee doesn’t have to prove that the employer was negligent so there is no litigation requiring that it was an employer’s negligent.

The only possible exceptions for employees and this is what I was talking about irrespective of faults, in many cases, work comp doesn’t cover if the employee who hurts themselves due to reckless behavior hurt themselves due to drug or alcohol abuse while they're working, who caused self-inflicted injuries. Of course they injured themselves while they're off duty.

At the end when we're starting to close out that work comp claim where we see a lot of the litigation and attorney involvement is how much benefit is that injured worker entitled to receive. What is their disability rating? What is the settlement amount?

Claims Processing

Look to your work comp regarding the medical coding rules and regs of authorization. Most of them have something out there for the processes of what is required. What happens if the payer denies the authorization? What's the steps to proceed through that?

Looking at the fee schedule basis, not all of them use the Medicare physician fee schedule as a basis. They may use like for example, the (sadient), and use the old (sadient) and these physician relative value units. They may use the usual and customary. So understand very clearly how much you're going to expect in payment. Make sure you're sending it to the correct payer to ensure accurate medical coding and billing.

And I'm starting to actually see a shift some payers to be able to accept work comp claims electronic and then you're going to submit the documentation be typically faxed or electronic sent with maybe a bubble coversheet that links the patient’s information to it. Those are certainly things that we're looking as we transitioning more and more to the electronic.

Be cautious about medical billing rules. Most states have regulations that are not allowable. Let's say we're billing $1000 of work comp fee schedule as $750. Most states, you cannot balance bill that patient for the balance of $250. It is based on that state fee schedule.

Our expert mentioned it in a medical coding conference that you must be careful for down coding. Down coding has been notorious in work comp. You're billing a 99215 and they pay a 99213. In some cases, they don’t even indicate it on the explanation of benefits. So that's why it's important to know how much you're supposed to get paid.

Look at timely filing, payment appeals and refund request. Be very aware of if there's state regulations or if it is the work comp regulations. Be very watchful for PPOs. And we've had over the past few years several PPOs that the provider practices have signed up form thinking they're going to get more work comp patients.

And then that PPO agreement is distributed across multiple payers. They’ve maybe posted the incorrect percentage amount. And so you need to be very, very aware of the silent PPOs and take a very active stance. If they're taking a percentage, let's say you have an agreement for 5% off the current work comp regs and they're taking 25% off, you need to aggressively work with that payer and/or your state division of work comp on trying to get that rectified as per medical billing rules.

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