Top Gun and Black Hawk Down – who’s seen them? One a fictional adventure of a rebel pilot and his loyal best friend and navigator. The other, a raw, tense and jarringly accurate portrayal of modern war. Together, these two movies inspired what I thought would be a career in the military. Fast forward to today, and I am posting a blog about the top four questions healthcare organizations have about workers’ comp claims – what the heck happened?
The First Platoon “Reapers” – Kirkuk, Iraq
Believe it or not, movies aren’t always great indicators of reality. Senior year of high school the Navy informed me I was color deficient, which disqualified me from flying. That’s fine, Top Gun wasn’t even that good… right? What I really wanted was to be on the ground and “in the fight”. So, I graduated college and became a Second Lieutenant in the Army. Eventually I got my turn to “go downrange”, which meant deploy to a war zone. This was it, my Black Hawk Down moment, everything had come full circle. After four years, reality trumped the fantasy. I resigned my commission and transitioned to healthcare.
Healthcare, like combat, is chaos. The landscape is constantly changing. Plans that look great on paper erode the second they are put into action. Patients’ lives are very much on the line and providers need every dollar they can get to provide the best care possible.
To support that mission, I’d like to go over some of the questions we get asked when talking with revenue cycle leaders about the reimbursement process related to workers’ compensation claims.
How much am I owed?
As a provider, you say X. The payer says Y. You have your state’s respective fee schedule but get told it’s out of date and/or not the right state for that specific case. But at least the clinical documentation is there to support the services rendered, right…The point is, it’s hard to pin down exactly how much you are owed. Even the most polished billing team will admit workers’ comp claims are complex and labor intensive and take equal parts knowledge, patience and persistence.
When I was in a small village in Iraq, our lead truck took a wrong turn and hit a parked car belonging to a local bread maker. As the platoon leader, it was my responsibility to ensure the man got reimbursed for the damage. I took down his name, snapped some pictures and gave him a business card with the location of the place he would go to collect his money. I filed my report and gave it to our legal team back on base – DENIED. I didn’t use the proper depreciation scale to estimate how much we owed the bread maker. So, I fixed it – DENIED. My pictures showed “pre-existing damage”, which we weren’t accountable for. Keep in mind the bread maker relied on his car to deliver his goods to nearby villages every morning around 4am. He needed his car and the money to fix it was held up over a dent we may or may not have caused.
The point is, I unknowingly made mistakes on my initial report that was submitted to someone whose sole job was to look for mistakes. My takeaway: nail the basics the first time around.
- Make sure the right questions are asked during patient registration
- Confirm you are billing to the right state and have the most recent fee schedule to match
- Based on payer tendencies, make sure the documentation supports the claim
We work with organizations in almost every state so if any of those tasks are causing you trouble, let us know and we can point you in the right direction.
Where do I send the claim?
That’s easy: to the payer that is responsible for the patient’s work-related injury. I’m envisioning a collective “screw you” being muttered by those who are reading this and know that is easier said than done. The fact is most patients have no idea who their workers’ comp carrier is. That mystery is left up to you, the provider, to solve. However, upwards of 65% of claims are initially sent to the wrong location.
When I went through the bread maker fiasco, this wasn’t an issue for me. I lived in a bunk so close to where I submitted my paperwork they could hear me cursing them out. Most billing teams probably don’t have that luxury, so coordinate with registration teams to ensure you capture as much patient information as you can.
- Does the patient know their workers’ comp carrier?
- Who is the patient’s employer?
- What is the contact information of the employer? Bonus if you can get a specific HR contact.
Knowing how important, yet overlooked, that information is, we’ve built scripts that help registration teams ask the right questions on the front-end to increase the odds of success on the back-end. It’s not rocket science, but we are happy to share what’s worked best.
It was easy to make a wrong turn in streets this narrow and cluttered
How do I send it?
Loaded question based on how you’re set up to bill. Electronic submission is the most efficient across the board. Some states even require that claims be submitted electronically. You probably know if your state is one of them, but what if you are billing out of state? Healthcare is keeping fax machines from extinction. Snail mail might be option – but this isn’t Amazon Prime. The manual approach takes time and eats into almost all time related billing KPI’s.
Some might find relief knowing a fellow top 5 GDP contributor, National Defense, hasn’t figured this out either. The list of things a Soldier wants to do after completing a 12-hour mission in 120-degree heat is short: shower, eat, sleep. Not on that list, hand delivering paperwork.
Assuming you won’t be hand delivering claims, know the right questions to ask:
- Are you required to submit the claim electronically?
- If you are mailing it, is the recipient’s address correct?
- What controls are in place to track the claim from out the door to delivery and back?
There are best practices that can be applied to each method. We use them all daily based on our clients’ needs. Let us know if you’d like to learn what we see works best.
How do I measure success?
You tell me! Every organization has a different definition of success. In some cases, aspects of workers’ comp reimbursement are out of your hands so organizations look at net revenue and put less weight in days to pay. Others look to “pass go”, collect their $200 while maximizing productivity and managing their AR. The key is identifying what’s important to your specific situation and securing the necessary data to measure success.
I never ran across the bread maker in Iraq again. I’d like to think we eventually did right by him and provided enough cash to fix his car and cover his lost wages. Sure, there was an appeals process in place, but the locals all knew to take what they could get when it was offered. Anything more required diving into an abyss of the unknown. Sound familiar?
Areas we find our clients value most may seem obvious but how much weight is allocated to each is never the same. The top 3 challenges we see being addressed:
- Increasing revenue
- Reducing AR
- Maximizing productivity
In the end, you need to know what you want to change. Define it, share it with your team and measure the results. If you’d like to discuss your goals with us, we would welcome the opportunity to learn about your organization and talk about how we might be able to support your efforts.
Top Gun and Black Hawk Down are still two of my favorite movies, but I’ve learned to manage my expectations. But if this healthcare thing doesn’t work out, I just watched The Greatest Showman and starting a circus looked fun…