Did you know that worker compensation transactions in the American medical industry amount to around
100 Million every year? Worker comp is a critical part of the total spending on billing operations
in the USA. Surveys show that 2 to 3% of the total expenditures on billing transactions go behind
managing worker comp claims. However, provider organizations sometimes find it challenging to take
care of the regular claims under the worker comp section since the in-house billing teams are not
always equipped enough to tackle the legal details. Medical billing services specialize in these
areas and can help the provider organizations improve the collections from worker comp.
When done right, worker compensation can improve the organization’s financial health to a
significant extent. However, it comes with its unique set of federal guidelines, terminology, and
forms. This makes the entire process cumbersome and challenging if the billing team is not trained
to handle the procedure. The time sensitivity of the process also adds to the pressure of the
already short-handed in-house teams. For these reasons, medical billing services serve as an ideal
partner for organizations to excel in this area.
Difference between Worker Comp and Group Health
The first step of improving the collections in worker comp cases is to train your assigned staff
regarding the basics of billing in this specialized area, which differs from the regular billing
terminologies. Medical billing services also hold regular staff training programs for your in-house
team to brush up their skills in this area.
Explanation of Benefits (EOB) is a crucial part of the medical billing process, usually used in
patient-insured health plans. In the case of worker comp, the terminology is Explanation of Review
(EOR).
In the case of the usual medical billing procedure, the patients themselves are the policyholders,
and hence their details are used in every process. Billing teams should be aware that in the case of
worker comp, the employer becomes the subscriber of the insurance.
The use of a regular healthcare identification number does not work in this case. Billing
professionals need to use a case file or claim number in its place.
Deductibles or co-payments charged in case of usual insurance billing are considered an illegal
practice in the case of worker comp. The provider organization needs to accept the compensation as
the full payment and not charge the injured worker for any outstanding bills.
Learning the basics of these specialized billing procedures from experienced professionals of
medical billing services can
scale the worker comp collections
in the long run for the provider organizations.
Steps followed by Medical Billing Services
Medical billing services appoint skilled professionals trained to operate these specialized claims
to improve the collections of the healthcare organization. Some of the leading RCM companies have
put forward these tips for scaling their operations.
State-issued guidelines are highly critical to improving worker comp claims management. The
guidelines vary between different states. Therefore hospital chains and healthcare clinics with
presence in different states in the USA should be careful about these state rules.
Medical billing services study the state worker comp guidelines well and assign different
professionals on a case-to-case basis to maximize the revenue and use the plan to the patient’s
advantage.
It is crucial to get all the information and enter them correctly into the system when dealing with
worker comp. In many cases, during the onboarding process, the patient might not mention that the
injury has occurred at their workplace.
Incomplete data like these will lead to the billing of the primary insurer of the patient instead of
the employer’s insurance. Later on, if the patient requests for billing of the employer’s insurance,
the practice is bound to charge the employer plan for the same and return the previous collections
to the primary insurer.
A small clerical error in the initial part of the process can lead to a string of complexities that
can slow down the revenue flow of the company. Make sure you maintain the patient’s records and the
provider’s notes properly to support the claims, including the First Report of Injury form.
Experts also comment that including any other findings and results into the reports is critical for
the patient to get the correct reimbursement without any hassles. Staff training professionals from
medical billing services can guide you with the process.
Worker Comp Claim Processing Structure
It is important to note down the necessary structure of the worker comp claim processing to
determine how you can improve your own system. Here are some of the points to note regarding the
steps of the process.
The CMS-1500 form is critical for the worker comp claim processing. The provider organization should
ensure that all details in the system are accurate and complete.
The form should also be attached to the diagnosis and treatment notes from the physician in detail.
The adjuster goes through the provider’s notes to see if the services are aligned with the treatment
plans of the patient.
Once the service is approved, the charge can be reduced depending on the carrier’s fee schedule.
However, the organization cannot bill the patient or their primary insurer for the difference in
costs.
Billing teams should check whether all the services in the claims relate to the work injuries or if
they are covered under the patient’s treatment plans.
In case the worker comp claims are denied by the insurance panel, the provider organizations cannot
hold the patients liable for these claims. They cannot charge the patient for any outstanding bill
in these cases.
We hope this article helped you understand how the worker comp collections work and how you can use
medical billing services to improve your revenue flow. For any queries, please write to us in the
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