Workers' Compensation Plans: Getting Patient Claims Paid

If you accept workers' compensation patients at your practice, it's a good idea to review the contracts for some of the finer details of how you will be paid. There are a few areas that you can look at today that will help you be paid tomorrow:

• State where the workers' compensation plan originated from. Believe it or not, different states use different codes. If you are seeing a patient for an extended visit and often code the same you would a patient that has Medicare for the same visit, you may not be getting paid. This can also be said that if you are coding for multiple workers' compensation patients, and one is an out of state plan, you may be paid for one and not the other using the same code. Investigate those adjustments to make sure this is not the case. You can find the codes you should be using in your contract, or at worst, you can call another physicians office in the state the plan originates from and ask them what code they use.

• What codes are actually paid by workers' compensation. Some workers' compensation plans will pay for a specific treatment, and others will not. It's important to track these items so you are aware of what will and won't pay. Otherwise, you are giving away care and losing a lot of money in the process.

• Oftentimes whether or not you are paid will simply rely on what is on the authorization form that came from the nurse case manager or adjuster. If there is something you'd like to do, and do not see it on the authorization, chances are you won't be paid for it on that appointment. Best to have your front-desk staff call and obtain authorization for the treatment you wish to perform. Sometimes you can get this authorization in as little as a few days up to several weeks, so plan accordingly.

• Are you contracted with Medrisk, but not Universal Smart Comp? If Universal Smart Comp is the actual payer on the claim, you won't be paid. I know this seems confusing, but when your staff verifies the insurance and contacts the adjuster, it's best to ask, "Who is the payer?" If it is a company you are not contracted with, you can request another payer whom you are contracted with.

Regardless of the reason for a denial, it is so important to really know and understand your contracts. There may be tips and ideas for getting paid that adjusters are not willing to share after-the-fact once the denial has happened. Many are not very helpful or are just plain hard to get a hold of.

With the changes coming over the next several months, I've found that workers' compensation groups are buying each other up, merging or partnering strategically like the big payers (Wellpoint with Blue Cross and Amerigroup, Aetna, and Coventry, etc.) this may bring many changes to the workers' compensation reimbursement structure.

As always, know your payer mix, know why your adjustments are as high as they are, and read your contracts closely.