Wiki W/C vs Health Ins

[LRizzitano]

I work for an ophthalmology office - a workers comp insurance company referred a pt over for an evaluation. Unfortunately, pt has ANA and the doctor could not due an evaluation until he does Yag PIs.
Do we bill the W/C Ins or the pts health ins for the 1st visit and Yags??? We have a debate going - each side presents good arguments.

Thanks

 

[CBLENNIE]

I work for a health insurance carrier we would expect that the first visit be billed to the workers comp (W/C) carrier as the visit was due to a referral from the W/C carrier.

If the visit is covered by the W/C carrier then it would be denied as related to a work place injury/condition which is excluded from coverage when there is a W/C carrier that is covering the service. If the W/C carrier denied it as not related to the work place injury/condition, it could be billed to the patient's health insurance plan.

The claim submitted to the health insurance plan should include a copy of the W/C EOB showing the service was denied, in order for the health insurance plan to process the claim under the patient's plan benefits.

For our organization, we will only cover something that is related to a work place injury/condition if we have a denial from the W/C carrier. So the claim must first be submitted to the W/C and only if they deny it will we then cover the service, assuming it is a benefit of the member's health insurance plan, with proof that the W/C carrier denied the claim.

As for the YAG PI treatment itself, since it sounds as if it is completely unrelated to the W/C condition, claims for these services could be submitted directly to the health insurance plan for processing of benefits available to the patient under their health plan.