One of the most challenging claims for an ASC billing office to process are workers' compensation claims. It is equally challenging to provide universal recommendations to ease the process since workers' compensation claims regulations vary from state to state. Therefore, the most important recommendation is to know your specific state rules and regulations for billing workers' compensation.
While each state processes workers' compensation claims differently, states generally adhere to one of three categories:
- States that don't follow a fee schedule.
- States with a fixed fee schedule.
- States with a percent-of-charge based fee schedule.
Based on research performed by the Workers' Compensation Research Institute, states without a fee schedule or a percent-of-charge fee schedule pay more per case. Regardless of the state and payment methodology, there are key processes that should be a part of your ASC's best billing practices to ensure successful adjudication.
Here are 10 recommendations to improve management of workers' compensation claims.
1. Obtain a complete history of the injury, including date of injury and any past procedures performed on each workers' compensation patient.
2. Confirm that the scheduled procedure is related to the injury.
3. Verify current contact information for the insurance adjuster assigned to the patient's case.
4. Confirm the procedures that will be performed and calculate the expected amount per the payment methodology in your state to ensure your costs are covered.
5. If you live in a fee schedule-based state and implants are considered inclusive to the procedure, obtain a "letter of agreement" from the adjuster verifying coverage of costs.
6. Ensure all authorizations from the carrier or adjuster are in writing. Never depend on a verbal authorization.
7. Register with the state workers' compensation board to stay abreast of the latest rules and regulations regarding changes to policy or payment structures.
8. When updates are posted for upcoming payment changes, perform a reimbursement analysis to understand the financial impact of each procedure on your facility.
9. In states that base payments on a fee schedule, know your options in the event that a case is underpaid. Depending on your state, you may be able to file a lien if the appeals process is unsuccessful. Inform the adjuster if the case isn’t paid correctly. You can also file a complaint with your state's department of insurance (department of financial services), if necessary.
10. Ensure that your ASC's physicians are contracted with as many workers' compensation carriers as possible. Some states require that providers and the facility be contracted with each carrier's medical provider network (i.e., an entity or group of providers set up by an insurer or self-insured employer to treat workers injured on the job).
Success is in the Details
If your ASC chooses to accept workers' compensation, it is imperative that you take a careful approach with each and every case. Know your state's rules and the process to help ensure you receive full payment for every procedure performed and service provided. Make sure you have a means to stay informed on regulatory and/or payor rule changes likely to affect workers' compensation. Working with experienced ASC billers, either in-house or through an outsourced billing company, can further help reduce the likelihood of your leaving significant money on the table.
Angela Mattioda (amattioda@surgicalnotes.com) is vice president of revenue cycle management services for Surgical Notes RCM. Surgical Notes is a nationwide provider of revenue cycle solutions, including, transcription, coding, revenue cycle management (RCM), document management and electronic health record applications for the ASC and surgical hospital markets. Mattioda oversees the SNBilling RCM service, the newest component of Surgical Notes' complete end-to-end revenue cycle solution offering.
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