Worker’s compensation, commonly known as workers’ comp, is a type of insurance that covers the treatment of injuries occurring on the job. Employers typically purchase commercial workers’ comp policies directly, although some states administer these policies. Medical billers
Workers’ comp claims are still processed manually, although most other health insurance claims are now processed automatically. The primary reason for this difference is that workers’ comp requires greater oversight to ensure the claimant has a work-related injury and receives injury-specific treatment. The billing procedure for workers’ comp consists of several phases, including filing the claim, patient treatment and processing the claim.
Filing the Claim
Employees who are injured on the job typically file a claim through their employer’s workers’ comp carrier. The employer’s Human Resources Department normally handles the claim, which is usually the extent of the employer’s involvement in the claims process. However, some companies also administer their workers’ compensation policies.
The employee then receives a claim number after the claim is filed, which serves as an ID number when receiving reimbursement for the treatment. The workers’ comp carrier will also assign an adjuster, who will authorize the employee’s treatment, review the employee’s recovery and coordinate the claims process. In some cases, the adjuster also authorizes the employee’s primary care provider to provide treatment or direct the employee to obtain treatment from the carrier’s provider network.
An employee becomes the healthcare provider’s patient once the adjuster authorizes the treatment. Services covered by workers’ comp aren’t billed to the employee’s private health insurance, although unrelated services provided in conjunction with the authorized services are billed to the employee’s own insurance. The provider also works with the adjuster to develop a comprehensive treatment plan intended to restore employees to their full pre-injury function.
Employees use the CMS-1500 claim form to submit workers’ comp claims, as is the case with other healthcare claims. However, workers’ comp claims don’t typically have a format that would allow for electronic submission. This is because a worker’s comp claim must be submitted with a copy of the healthcare provider’s notes documenting the treatment indicated by the claim. Medical billers must also fill in the fields on the CMS-1500 to indicate that the employee’s condition is work-related, including the date of injury. They will use the workers’ comp claim number instead of an insurance ID number to ensure the correct injury was appropriately treated. Workers’ comp claims made to government or commercial healthcare plans must also be placed on hold until the carrier can determine if workers’ comp will cover the treatment cost.
Processing the Claim
The adjuster reviews the charges on the CMS-1500 and the attached progress notes to ensure the provided services are related to the work-related injury and authorized under the treatment plan. Payment for unrelated and unauthorized services will be denied, but the employee can’t be held liable for those expenses. Furthermore, the healthcare provider can’t bill those charges to the employee’s personal insurance since they’re under the jurisdiction of the workers’ comp plan.
The adjuster revises appropriate charges according to the carrier’s fee schedule. Like other forms of healthcare, providers aren’t allowed to bill patients for any remaining balance on workers’ comp claims. Providers also agree to accept the fee schedule rates as payment in full, since workers’ comp doesn’t typically include co-insurance or co-payments.
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