Medicare Compliance & Reimbursement

Streamlining processes and doing some research on the ground will help reduce hiccups.

Claims falling under worker’s compensation (WC) can be challenging and complicated. Make sure you gather all the essential information you’ll need before your provider sees the patient to make certain that your practice gets paid.

Review these top three frequently asked WC questions, and the expert answers, to ensure your practice is on track.

1. Consider Separate WC Encounter Scheduling

Question: As an internal medicine practice, we see a good chunk of worker’s compensation cases. It isn’t unusual for a patient to come in about an injury that qualifies for WC billing, but then also ask the doctor to address another complaint that is not related to the WC claim. Can we bill WC and regular insurance for one office visit that encompasses two different problems?

Answer: Your internal medicine physician can technically and legally see a patient for a WC visit and other unrelated problems on the same day, but you may find it easier in the long run to keep the visits separate. Otherwise, you’ll be sending claims to two different payers if your physician treats the WC condition and an unrelated problem in the same visit; one claim will go to the WC payer and the other to the patient’s normal insurance.

Best bet: If a patient wants to discuss other issues, try to have him schedule a new appointment so you’ll have a clearly separate record for the WC claim, recommends Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. Although medical necessity or good patient relations may require the physician to treat unrelated problems during a workers’ comp visit, the best scenario is to have the patient return for a separate appointment to address other nonrelated problems.

If the physician chooses to see the patient for both problems in one visit, tell the doctor to dictate separate notes for the workers’ comp claim and the unrelated problem. Having a clear and separate record for your workers’ comp claim will help reduce payer confusion and expedite payment, Hammer explains. Be sure that the E/M code your coder selects for the non-WC portion of the encounter does not include any work done for the WC claim. You cannot “double dip,” Hammer adds.

Warning: Having separate WC documentation can also protect you from HIPAA violations. “Most WC jurisdictions require the notes to be sent along with the claim,” Hammer says. “If the provider includes non-WC related information in the single note, there potentially could be a HIPAA violation of disclosure of more PHI than minimally necessary.”

Tip: Your physician might also treat WC patients who have multiple injuries that have happened on different dates and are for different body parts. Those have to be scheduled in separate time slots, with separate encounter forms and separate dictations.

2. Do Some Fee Schedule Research

Question: I hate to waste staff time and resources looking up fees on the WC payer’s fee schedule for every claim we file. Do we need the WC fee schedule to set our pricing on the claims?

Answer: You don’t technically need the WC payer’s fee schedule to bill claims, but you might want to reference it, because following their fee schedule might actually increase your revenue. For example, you might normally bill $200 for a procedure but discover that the worker’s comp fee schedule will reimburse you $300.

Option: You can also submit claims based on your practice’s normal fees, Hammer says.

If your practice sees a fair percentage of worker’s comp patients, know the fee schedule for your state and any nearby states with whose claims you sometimes deal. Big payers sometimes process your claims in another state, and reimbursement can be incorrect because their computers are dealing with several state fee schedules. Knowing your state’s fee schedule allows you to verify that you get paid what you deserve.

3. Start Before the Patient Comes In

Question: When should we capture the details about the injury and how it happened when we are dealing with worker’s compensation? We wait until the patient comes to the office for her appointment and the medical assistant goes over all the details. I think it is slowing down our claims, however.

Answer: Your practice’s work on a WC claim should begin before the patient even sets foot into your office, Hammer says. When a patient calls to schedule her first appointment for an injury that could have been on the job, such as wrist pain, the first question your staff should ask is: “Is there a chance that this injury is work-related?”

If the answer is yes, you should collect as much pertinent information as possible over the phone, such as date of injury, workers’ compensation payer, claim number, employer at the time of injury, adjuster and/or case manager name and phone number, and alternative private insurance information.

Beware: The patient often won’t tell you the reason she needs to see the doctor is related to a WC claim if you don’t come right out and ask. So take your cue from the reason for the patient’s visit. If it sounds like it could be a work-related injury, go ahead and ask. “Also a good point to make is that if the provider does determine that the patient’s condition is work related, the ‘back office’ staff also needs to be responsible in letting the front office/billing staff know,” Hammer says. “Often this can be the case for carpal tunnel syndrome where there wasn’t really an observed injury such as a fall.”

The most common mistakes offices make with workers’ comp claims are gathering incomplete information and not knowing whom to call with questions, Hammer cautions. To make sure you don’t fall into these traps, be sure you get the following information when the patient makes the appointment:

• Date of injury (this is especially important if the patient has multiple claims opened).
• Type of injury.
• Claim number.
• Name and telephone number of the insurance adjustor or case manager.
• Patient’s employer at the time of injury.
• Workers’ compensation carrier.
• Alternate private insurance information.
• Attorney’s name and telephone number, if applicable.

Key: After getting the information from the patient, you may need to get in touch with the WC insurance company’s claim adjustor to obtain authorization to treat the patient before the initial visit.