Workers’ compensation claims take up a disproportionate amount of resources to resolve when navigating through the complexities associated with on-the-job injury claims processing. They are so complex, even the insurance companies themselves find it challenging to resolve this class of claims.
In order to maximize reimbursement for work comp claims, it is imperative to maintain a succinct follow-up process to ensure correct payment is received. Unfortunately, many standard collections and accounts receivable management tools don’t adequately support the workers’ compensation process. Hospital PFS teams need customized workflows to keep track of expected payments, multiple deadlines, and documentation that typically needs to be sent and re-sent.
Workers’ comp claims tend to reach a tipping point where the resources required to collect become costlier than the potential reimbursement itself. In this instance, most organizations pass off stingy open A/R to a third-party. Upon receipt, the workers’ comp specialists at these third-party organizations will scrub the claim to identify where the snag is, correct it and resubmit and/or appeal on the hospitals’ behalf.
With labor shortages and high turnover rates, many hospitals lack the bandwidth to combat the various challenges posed against them to properly handle workers’ compensation claims. This does not mean that workers’ comp billing is like “fighting a losing battle.” This means that either the right technology needs to be in place, and/or the below processes need to be implemented and acutely followed to increase workers’ compensation reimbursement:
- Payer Verification and Review: This process is necessary to identify the correct payer and address for bill submission to ensure that bills are going to the right place the first time to expedite payment to the hospital. To ensure proper payment, all EOBs must be reviewed, and accounts compared on a line-item level.
- Denial Management: Proper management of this process allows for a quick identification of workers’ comp claims and provides the necessary documentation to promptly pursue reimbursement from the health insurer or the patient.
- Status Documentation: This is necessary for consistent collection notes to be documented and uploaded into the providers database to ensure that patient account status is updated.
Payer Verification and Review
The payer verification and review process is cumbersome and requires billing staff to know and understand the intricacies of workers’ comp claims specific to coverage and payer compensation rules by state. The purpose of this process is to determine whether an employer has workers’ compensation insurance in the given state the claim is issued. Work comp coverage verification will provide the name of the insurer that wrote the policy for a specific employer on a specific date.
Denial rates tend to be higher for workers’ compensation claims—often as much as 35%.
From a billing perspective, the top reasons for delays and reversible denials can be pinned squarely on clerical errors—and not just typos or misspelled names. The work comp claims landscape is rife with coding and billing requirements that differ from commercial and government insurance plans. As a result, inexperienced hospital PFS teams tend to miss key components of the workers’ compensation claims process.
If a claim is ultimately rejected, hospital PFS teams must move quickly to locate and file to the patient’s commercial insurance carrier. Timely filing deadlines for commercial insurance are often shorter than the workers’ compensation process, so claim representatives have to be well-trained and ready to switch course.
Reimbursement calculations are not simple. Elements such as fee schedules and references to Medicare reimbursement components can change quarterly or even more frequently. Also, some work comp programs base their reimbursement on outdated DRG groupers, which may make conferring proper payment an even greater challenge.
To receive workers’ compensation benefits for a work-related injury or illness, you must file a work comp claim within a certain period of time. Each state’s law (or U.S. law for employees in the federal workers’ comp program) sets the deadlines for filing claims, reporting the injury directly to your employer, and other matters related to your workers’ comp case. Those deadlines can be quite different from state to state. But the bottom line is, the sooner the better.
Given that workers’ compensation cases usually account for 3-5% of a hospital’s revenue, the reimbursement calculation is not always built into the contract management systems hospitals typically use. In addition, the electronic transactions used by these systems, such as 835s, are not normally available from work comp payers.
With a custom system to follow up on workers’ compensation claims, EnableComp can pursue inappropriate denials and underpayments and reduce recovery time below 60 days with AR over 90 at less than 20%.
Ultimately, outsourcing these confusing and time-intensive claims to a trusted partner will allow you to work toward the highest net return while also receiving the highest levels of administrative effectiveness and patient satisfaction. A partner like EnableComp can get you there – our proprietary technology, Enforcer360, is the most efficient provider-based comprehensive workflow engine in the marketplace. With built-in reimbursement modeling, underpayment identification, and embedded federal and state reimbursement rules, our software provides the highest yield and best-in-class outcomes in less time leading to a real bottom-line impact for providers! Our 1,000+ clients across the nation are experiencing an average 20% uplift and 100% collection of net expected reimbursement within 60 days.