Optometry Coding & Billing Alert

Knowing which state has jurisdiction over the claim is the key to success

If the thought of workers- compensation (WC) claims gives you a headache, you-ll want to incorporate these expert tips into your billing process to take some of the work out of WC encounters.

Look at these two common questions -- with answers from the experts -- to get the scoop on what you need to do to ensure proper WC claims processing.

Question 1: Which state's rules should I follow?

The biggest area of confusion is that each state administers its own workers- compensation program. "There is no clear guideline, as it is different from state to state, contract to contract," says Donna O-Hern, CPC, chief auditing officer at Parses Inc. in Tampa, Fla.

Bottom line: You need to follow the rules of the state in which the patient originally filed the WC claim.

Caution: Keep in mind that this may -- or may not -- be the same as the patient's current state of residence. You may encounter cases in which a patient receives care in a state that does not have jurisdiction over the patient's WC claim.

"Only one state will have jurisdiction over a workers- compensation claim," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. "It is typically the state in which the claim was initially filed."

Test yourself: A patient is injured in Colorado and files a claim with Colorado. Then the patient moves to Florida and receives care in Florida for the Colorado WC claim. Which state's WC regulations apply to this patient's treatment?

Colorado rules apply to this WC claim rather than Florida, because the claim originated in Colorado.

Exception: The only exception is WC for federal employees, which has nationwide rules. "Federal WC jurisdiction covers all federal employees regardless of where the injury occurred," Hammer says.

Where to look: Each state has a Web site for information on WC claims, so check your state's site for more information on individual state regulations and specific state policies about submitting your claims. Also, there are some general WC information Web sites, such as http://www.workerscompensation.com, that have links to individual state Web sites.

Question 2: What information do I need to ensure smooth WC claims processing?

To process WC claims, you-ll need the claim number for the specific injury, the injury date, the employer at the time of the injury, the adjustor name and phone number, the payer, and the address to which you should send claims, Hammer says.

Be proactive: When a patient comes to your office with a presenting problem that might be from his job, your office staff should first ask, "Is there a chance this injury is job-related?"

Tip: Make sure you create a separate case in your practice management software for each WC claim that includes the injury date so it goes on your claim forms.

More information: To learn more about WC regulations and ensure that you-re up to speed on this complicated process, attend Hammer's "8 Guaranteed Strategies for Workers- Comp Claim Success" on Tuesday, Nov. 13. Visit http://www.audioeducator.com/industry_conference.php?id=527 for more details.