Getting Paid on Workers’ Compensation Claims

Collecting on workers’ compensation claims can be an exasperating exercise for healthcare providers.

Between special terminology, unique collection forms, and numerous logistical hoops, many practices simply don’t have... ​

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Getting Paid on Workers’ Compensation Claims

Workers’ Comp Can Be a
Major Headache for Healthcare Providers

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Collecting on workers’ compensation claims can be an exasperating exercise for healthcare providers. Between special terminology, unique collection forms, and numerous logistical hoops, many practices simply don’t have the resources or expertise to properly collect on these claims.
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Workers’ comp is designed to reimburse lost wages, as well as the costs of medical treatment and rehabilitation, to employees who are injured on the job or who contract an occupational disease. But when it comes to collecting on claims, the program is very different from standard health insurance in a number of ways.

A Myriad of Rules 

Worker's comp is highly specialized. Health insurance carriers that offer it don't sell standard plans, and standard health insurance carriers don't offer worker's comp. If a worker’s comp claim is submitted to the wrong payer or administrator, you risk violating state filing requirements.

Workers comp claims also use special terminologies and unique collection forms. For instance, in the world of standard health insurance, the policyholder is typically the patient. Not so with workers’ comp, where the employer is the subscriber. The explanation of benefits (EOB) is an explanation of review (EOR) in workers comp. Also, claims are identified through a case file or claim number, instead of healthcare ID.
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Workers’ comp has no deductible or copay linked to the claims. More importantly, compensation paid to the provider through workers comp must be accepted as payment in full. Billing the patient for any outstanding balance is illegal.

Reporting Requirements

Providers who wish to collect on workers’ comp must submit regular reports to the state in a timely manner. The reports document initial treatment and follow-ups, as well as any relevant discussions between the provider and payer. Each state has its own specific reporting requirements regarding formats and timeframes.
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Also, before you can even file a claim under workers’ comp, you must obtain a First Report of Injury Form from the patient’s employer. (This form also differs by state.) The provider should complete the form when the patient first seeks treatment for his work-related injury or illness. Failure to obtain this pre-authorization could have a seriously adverse impact on the reimbursement process.

​​Follow-Up and Verification 

Once all the appropriate forms and reports have been properly prepared and submitted per the state’s requirements, frequent follow-up is often needed to ensure timely processing of reimbursement.​

After reimbursement is received, the provider must then check the accuracy of each payment, to ensure the payer is using the correct fee schedule. If there is an over-payment or under-payment, the provider must file an appeal in a timely manner.

Or...Let Us Do It for You

It’s easy to see how getting paid for workers’ compensation claims can be a real struggle for providers. With so many rules and procedures that must be followed to the letter, as well as resources needed to manage the program, they could end up actually losing money, by the time it's all said and done.

But not every aggravating job has to be handled internally. At Reliant Financial Services, we're experts in workers' compensation. We can handle all aspects of these claims — from start to finish. By partnering with us for your workers’ comp claims, you’ll not only minimize problems for your staff, you’ll be freeing them up for more meaningful work.

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Sources:
Featured Image: Adobe, License Granted
​RevCycle Intelligence
Becker's Hospital Review
Thomas, Coon, Newton & Frost