Workers’ Compensation Challenges: Unlocking Hospital Revenue Potential

Posted October 18, 2023 by Zachary Schultz

Workers’ Compensation (WC) has a worthy twofold goal: providing financial protection for employees injured on the job while protecting the employer from negligence lawsuits that could potentially bankrupt the company. But the complexities of WC claims can be a severe strain on the hospital revenue cycle management (RCM) staff who must process them. These claims are often among the most challenging, consuming valuable resources and creating additional questions and confusion. Understanding how best to handle WC claims can help your company maximize this valuable revenue source that often receives insufficient attention. 

Workers’ Compensation Claims: A Multifaceted Challenge 

Although all 50 U.S. states have some form of Workers’ Compensation in place, each runs its own program, determining for itself how to manage claims. That means different rules, regulations and reimbursement from state to state, increasing the complexities faced by hospitals and healthcare systems that operate in more than one state. 

Even for providers operating in just one state, there are plenty of pain points, including these common ones: 

  • Fraudulent claims. Some workers’ comp claims are made for injuries that did not occur at work or that are less severe than stated. Hospitals’ efforts to detect and respond to such claims can strain resources. 
  • Strict pre-authorization requirements. Failure to meet strict pre-authorization requirements that some insurers place on certain workers’ comp medical procedures or treatments can cause claim denials. 
  • Inconsistent and changing regulations. Regulations and guidelines not only vary by state, but also change frequently. Without specialized expertise, hospitals can spend inordinate amounts of time trying to stay abreast of the latest requirements. 
  • Complex processes and insufficient documentation. The administrative processes involved in these claims can be difficult for hospitals to navigate, leading to delayed reimbursement. The medical reports, treatment plans, injury documentation and other data necessary for a successful claim can tax a hospital’s capacity for maintaining and assembling them. 
  • Disputed claims and delayed payments. Insurance companies or employers often dispute WC claims, leading to protracted negotiations or litigation. Payments are sometimes delayed even when claims are legitimate and properly documented. 

In the event of a denial, providers have recourse, but in order to resolve the issue they must first understand the system, starting with the reason codes at the bottom of the explanation of benefits (EOB). Most denials are due to insufficient documentation, failure to obtain authorization from the WC insurer, coding issues on the bill, or the employer’s assertion that the injury is not eligible for compensation. 

Utilizing Day One billing practices is essential for hospitals and healthcare systems aiming to avoid denials or delays. It is important to ensure that all necessary information and coding are meticulously included in the initial claim submission. A partner that specializes in WC claims can be invaluable, using its technology, specialized experience and expertise to track and manage changes to WC programs, interpret the ever-changing rules, and drive corrective actions. 

Uncover Needed Revenue: Partnering With EnableComp 

EnableComp, which specializes in using a combination of proprietary technology, automated processes and expert teams to manage complex claims, knows how to meet pre-authorization requirements for treatment, detect potential fraudulent claims, and ensure that patient intake specialists ask the right questions to obtain all the information necessary to begin the claims process. 

This team of experienced RCM professionals, clinicians, coders and lawyers acts as an extension of your RCM team, providing the depth and breadth of knowledge and experience needed to successfully process these complex claims, whether aged-out and zero-balance accounts or Day One issues. EnableComp’s proprietary Enforcer360 platform electronically files claims at a rate 10 times higher than the industry average. The result is higher reimbursements with fewer delays. 

When it comes to WC, EnableComp has demonstrated success in getting claims to the right payer at the right time for the right amount. Our successes include:

  • 95% of bills submitted within seven days of initial drop
  •  60 days average to total payment, with less than 20% of A/R greater than 90 days
  • 95%–100% of the maximum amount collected

Ready to maximize reimbursement at the lowest contingency fee? Discover expert insights, strategies and success stories that will empower your team to navigate the intricate world of complex claims with confidence. Download our free e-book today