There’s a reason that workers’ compensation claims fall into the category of complex claims: They are, in fact, complex. By complex we mean complicated, confusing and inconsistent, as well as mind-numbingly tedious. That doesn’t mean you should avoid them, however, because they can represent enough money to make a significant difference to your bottom line.
Considering all the steps involved, you might wonder which is the most important. The answer to that question is a bit tricky, as they are all extremely important. The oh-so-crucial first step, of course, is recognizing the importance of processing these claims. Without this recognition, healthcare revenue cycle teams risk ignoring workers’ compensation, or placing such a low priority on it that they are unlikely to pursue those claims with any vigor. After all, considering their thin margins, short-staffed teams and other limited resources, something has to give.
Often hospitals and other provider organizations don’t realize how much money from complex claims they are leaving on the table. While this money is a small percentage of total revenue, and a CFO might not realize its value, our experience is that revenue cycle directors do see the dollars that are being lost. But, given their limited resources and with a lack of buy-in from the C-suite, they may feel powerless to do much about the situation.
Before your organization fully commits to pursuing this important but often overlooked chunk of revenue, it needs to 1) understand just what is involved, 2) get started on the right foot, and 3) realize that guidance and help are available.
Why Are These Claims So Complicated?
- States Make Their Own Rules
Unlike Medicaid and Medicare, workers’ compensation is not a federal program but instead is administered at the state level. That means each state has its own rules and regulations on how claims are coded, processed, billed, and reimbursed. Different rules also apply to the supporting documentation required and the timelines for gathering and submitting it.
- There’s No Secondary Insurance
In addition, with workers’ compensation, there is no secondary insurance. Once an injury has been established as a workers’ comp case, everything related to the accident is covered. The provider cannot bill Medicaid or Medicare for any services.
- Proper Coding and Documentation Are Essential
To receive timely and accurate reimbursement, providers must take pains to ensure that coding and documentation are correct. The process begins with the coding and generation of a claim, and coding issues are one of the top reasons for denial of a claim.
A key piece of documentation is the “first report of injury” document. A claim does not become a work-related claim without this form, which establishes compensability, or eligibility for coverage. The document describes the nature of the injury, the nature of the accident, and the injured body part, and agrees that the accident happened at work. The form must be submitted to the appropriate insurance company; sending it to the wrong place or missing the deadline can result in a denial of the claim.
- Pre-authorization Happens Later
Typically, in workers’ comp, anything scheduled will be pre-authorized. The issue of pre-authorization wouldn’t come into play until after the emergency room visit. Say you go to the ER with a broken leg. The hospital files the claim. Once the claim gets filed, the first report of injury gets filed. A case manager gets assigned to the patient, and then any follow-up treatments and appointments get authorized ahead of time. Physical therapy is a good example. All your therapy would be authorized before visits were scheduled.
A lot of in-network care will have a pre-authorization assigned to it. If not, sometimes the provider can do a single-case agreement in which the workers’ comp insurer will get with the hospital and say, “I know you’re not in network, but we want to authorize 20 visits of PT with you at this rate.” In such a case, the pre-authorization still happens, but a little later in the process.
While there are several other steps, including follow-up and (if necessary) appeal, starting off with accurate coding and generating is the one most likely to make the entire process go smoothly and ensure your prompt and complete reimbursement.
Consider a Partner With Specialized Expertise
Unless you have a large revenue cycle team with plenty of time to keep abreast of the workers’ compensation rules in the states where you operate, it may make sense to find a partner that specializes in this special category of complex claim. EnableComp is just such a partner. Having built our business on workers’ compensation more than a quarter-century ago, we have the expertise, experience and technology to get the job done right.
Our E360 RCM™ intelligent automation platform electronically files claims at a rate 10 times higher than the industry average, bringing you higher reimbursements with fewer delays. E360 RCM™ integrates seamlessly with your EHR/HRIS system, the “source of truth,” and allows us to provide notes and updates directly in the system.
We understand the intricacies of workers’ compensation from state to state and maintain a wealth of claims intelligence, so we can easily shift from one state jurisdiction to another. And our reporting lets you see, in detail, the ROI from your partnership with EnableComp.
With all this help available, one could well make the argument that the most important step in processing one’s workers’ compensation claims is deciding to let EnableComp handle them.
Download our eBook
For more information, download our free eBook Taking On Workers’ Compensation Claims: A Healthcare Provider’s Guide to the Process and Its Risks. Or contact us to schedule a consultation.
