Wiki Understanding Workers Comp

[TJAlexander]

Please HELP!

I really need help understanding the whole workers compensation process when it comes to medical billing. I understand that if the WCIC is owned by a commercial carrier (Aetna, UHC) then we are FORCED to abide by contractual obligations because our contract supersedes any state guidelines when it comes to payment. However, we are currently dealing with a situation that I have no idea how to resolve.

We treated a workers comp patient from May 2022 through June 2023; 45 visits total including office visits, surgery and physical therapy. The patient's company uses Amtrust as their WCIC. We haven't been paid in accordance with the GA WC Fee Schedule for any of these visits. Initially, we contacted Amtrust who would direct us to contact Mitchell who would advise us to contact Procura who would advise us to contact OneNet(Optum) who would then tell us that because we have a contract with UHC that they are not obligated to abide by the GA WC Fee Schedule. No one takes ownership of the situation and no one can suggest how to resolve the issue of underpayment. How is this allowed to happen? Can someone please explain this to me?

If we submit a claim to one insurance company, how does a 4th party get to dictate how we get paid?

I would really love some advice here....

Thank you!

 

[TThivierge]

Hello TJ
I d first ensure each provider treating patients with work comp claim in the setting of clinic, office or hospital is credentialed with statewide WC or most common worker comp company for differ employers in your state area. Each provider should get a special ID # in conjunction with their providers NPI. Also each pt. has approval ID# given to use for the care which came from work related injury from the work com payer, need pt. soc sec, DOB and date of injury -DOI and approval from employer.If pt arrives and needs approval for ongoing dx problem which is w.comp should have approval number and same dx problem unless it worsen. The WC payer will only cover for THAT DX or ILLNESS approved. At times patient arrive not tell you it is work related, but their personal job commercial insurance billed .This happens and ins payers for WC might not pay if not gotten approval first. The above scenario sounds like it was never approved as WC claim but billed with pt private comm insurance. Id just get approval from work comp if pt needs still need care. Other words the funds are lost from payer but may have to bill patient.
I remember once at one of my past job in processing a worker claims the pt. got hurt at work (broke his hand-he got upset with his boss then hit the wall at work) because of his fault of not following company policy/procedures in getting verbal disciplined. Thus employer & W Comp refuse to pay the claim. So his private insurance was billed and deductible not met. The pt was billed.
Well I hope helped you but there might be more to the story
Lady T