Workers' compensation, also known as workers’ comp, is a type of health insurance that covers injuries incurred at work. Employers must purchase workers’ comp directly in most states, although some states administer these policies. Workers' compensation billing service providers must be aware of the guidelines for their particular state, including requirements and limitations.
The claims for most health insurance policies today are automatically processed through electronic data interchange (EDI). However, workers’ comp claims still must be processed manually due to the greater oversight they require. The primary reason for this need is to ensure the claim is for work-related injuries. The process for filing and collecting workers’ comp claims has characteristics that are common to many types of health insurance, but it also has aspects that are unique to workers’ comp.
Employees who are injured on the job should submit a claim with their workers’ comp carrier, usually through their employer’s Human Resources Department. This step usually marks the end of the employer’s involvement in the claims process, unless the employer administers its workers’ comp policies. The employee receives a claim number from the carrier after the claim is filed, which serves as an insurance ID number in future correspondence with the carrier. The carrier also assigns an adjuster, who will coordinate the employee’s care by authorizing treatment and reviewing the employee’s progress towards their former health status. The adjuster may direct the employee to receive treatment from providers in the carrier’s network or from the employee’s own healthcare provider.
How to File Workers' Comp Claims
Injured employees will provide their primary care physician with the information needed to file a claim for their services, including the claim number and date of injury. The physician’s staff will then work with the adjuster to develop a treatment plan with the primary goal of restoring the patient’s health status. The patient’s personal health insurance won’t be billed for services covered by worker’s comp, although it may be billed for unrelated services provided in conjunction with authorized services.
Medical billing services submit workers comp claims on the same CMS-1500 claim form used for all other healthcare claims. However, workers’ comp claims don’t have a format for electronic submission since these claims are always processed manually. The biller must also fill in fields in the CMS-1500 that indicate the claim is for a work-related injury and the date of the injury. The claim will then be placed on hold until the carrier can determine if workers’ comp will cover the cost of the provided services.
How Claim Processing Work
A CMS-1500 for workers’ comp should be accompanied by notes from the physician, which allows the adjuster to ensure the services conform to the treatment plan. If the adjuster approves the service, the charge may be reduced according to the carrier’s fee schedule. The physician isn't allowed to bill the patient for the difference between the actual charge and the amount on the fee schedule, as is the case with other types of health insurance. Claims that aren't related to work injuries or are unauthorized under the patient’s treatment plan should be denied. The physician can’t hold the patient liable for workers’ comp claims that are denied, nor can the physician bill the patient’s personal health insurance for such services.
Related Article: How to Perform Workers' Compensation Billing
The time needed to process a workers’ comp claim is typically about 45 days since it must be submitted through the mail. Submitting a claim on a paper form also requires the entries to be legible and properly aligned to ensure they appear in the proper field.
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