Medicare Compliance & Reimbursement

If you don't get pertinent information before seeing the patient, expect trouble when you start the billing process.

Problem: One of the major points of confusion is that, while workers' compensation is authorized with federal guidance, it is a state-run program. That is, each state has its own rules, fee schedule, and process. Add in the fact that federal and railroad employees have their own workers' compensation (WC) programs and your head might spin.

If you follow these five guidelines from the experts, you'll be able to clear the confusion and steer your practice toward clean WC claims that won't make you want to file your own pain and suffering complaints.

1. Capture All Pertinent Claim Info Before the Patient Comes In

Your practice's work on a WC claim should begin before the patient even sets foot into your office. When a patient calls to schedule his first appointment for an injury that could have been on the job, such as a sprained back, 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 carrier, claim number, employer at the time of injury, adjuster and/or case manager name and phone number, and alternative private insurance information.

Watch out: 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.

Pointer: "We have to be very careful how we ask the questions, because you'll get an answer and it may be a correct answer but it's a correct answer to a different question," cautions Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. For example, the front desk staff might ask the patient "What's your insurance?" and the patient will give his normal health insurance information rather than the workers' compensation insurance data.

The most common mistakes offices make with workers' comp claims are gathering incomplete information and not knowing whom to call with questions. 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 need to get in touch with the WC insurance company to obtain authorization to treat the patient before the initial visit.

"A phone call to the WC carrier is a good idea, before the patient is seen," explains Linda Huckaby, CMA (AAMA), with Carolina Medical Rehabilitation in Greenville, S.C. Ask: "Is this really a WC case? Is our office authorized to see the patient? Is a pre-authorization required for each office visit? Who is the adjuster or case manager?" she adds.

Good practice: "We have the adjuster call, not the patient -- that way we can ask particulars about the claim," says Kristine Newton, CPC, billing coordinator for Sarasota Orthopedic Associates in Fla. "Many times the newly injured person has not a clue and cannot answer some of the questions we pose."

Problem: "Jurisdiction is probably one of the most confusing things for workers' comp for physician billing and office staff," Hammer says.

"When we have had this situation come up, we are bound by the rules of the state where the accident occurred," Huckaby confirms.

Example: A billing data-entry employee in Ohio has a computer monitor fall on her head. This first report of injury is filed with state of Ohio. The patient's recovery is prolonged, and during the recovery and treatments the injured employee moves to California with her spouse and receives medical treatment now at your practice in California.

"The California provider needs to understand which state regulations now apply -- is it going to be California because they're now being treated in California or is it going to be Ohio," Hammer explains. "In most cases, it's going to be Ohio."

Note: This may or may not be the same as the patient's current state of residence. For example, a truck driver may initiate care for an injury in a state other than where he lives.

Good news: Federal employees fall under federal rules, which are standardized nationwide, so you avoid the "which state" dilemma.

Alternative: You can also submit claims based on your practice's normal fees. "We bill our usual charge and then make any adjustments when payment is received," Huckaby says.

"Our office bills according to our fee schedule and the carrier applies the contractual adjustments when they send payment with their EOB," Newton explains.

Keep in mind: Not all workers' compensation carriers use the Medicare physician fee schedule as their basis, Hammer warns. "So understand very clearly how much you're going to expect for payment," she adds.

Pointer: For practices that see a fair percentage of workers' comp patients, you should know the fee schedule for your state and any nearby states whose claims you sometimes deal with. Big carriers sometimes process your claims in another state, and reimbursement can be incorrect because their computers are dealing with several state fee schedules. Having knowledge of your state's fee schedule allows you to make sure you get paid what you deserve.

While your physician can technically and legally see a patient for a workers' comp visit and other unrelated problems on the same day, you may find it easier in the long run to keep the visits separate. Keep in mind that you'll have to send 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 carrier and the other to the patient's normal insurance.

"This is not a situation that we deal with since we are a specialty group. But, visits like this can be billed," Huckaby says. "Great care must be taken to be sure all the information is filed to the appropriate payer."

Additionally: You may also see WC patients who "have multiple injuries that have happened on different dates and are for other body parts," Newton says. "Those have to be scheduled in a separate time slot; with separate encounter forms and have separate dictations."

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 your workers' comp claim. Although medical necessity 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

If you provide durable medical equipment (DME), you may need to jump through a few extra hoops to ensure you get paid for those services as well as the office visit and treatment services or procedures.

"Some carriers (Department of Labor especially) require prior authorization for durable medical equipment," Newton warns. "Be sure to have these pre-authorized prior to dispensing. Having the patient sign an ABN (advance beneficiary notice) is often worthless."

Plus: "When filing DME, injectables, [and] medications, most WC carriers want a hard copy of the invoice for that particular item," Newton says. "Be prepared to send that along with your initial filing so the claim is clean when you send it the first time."