Workers' Compensation Billing
by Jackie Stack, AAB, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC, CCP-P
Workers compensation billing can be confusing at times. Knowing a few background guidelines and rules can help you along the way. Workers’ compensation provides coverage for wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to workers who are injured at work or acquire an occupational disease. There are federal and state laws that require that employers maintain Workers’ compensation coverage to meet minimum standards.
Occasionally a patient will come into an office and see a provider for an illness or injury that is work-related; however, the patient fails to inform the provider that the illness or injury is work-related. If this happens, the patient’s primary payer then gets billed for the services or procedure. If the patient then requests that his/her workers’ compensation insurance be billed for the service and the primary payer has already paid the provider, the workers’ compensation insurance will need to be billed. If the workers’ compensation claim is denied, an appeal will need to be initiated. The reimbursement paid by the primary payer must be returned.
Sometimes a patient will present to the provider for a workers compensation injury and also wish to be seen for a reason unrelated to the employment injury. Providers must be cognizant of the need to keep both encounters separate, with separate encounter forms.
Keep in mind that HIPAA privacy rules must be followed, and illness or injuries unrelated to a workers’ compensation injury should never be billed to the employer.
Billing for workers’ compensation claims can differ from state to state, sometimes making it problematic. Knowing you state’s regulations, which are established by your state commission, will keep your practice in compliance. However, there is general nationwide billing information for workers’ compensation claims that does help keep billing somewhat uniform.
It’s important to utilize the correct forms when billing for workers compensation; these forms include the First Report of Injury Form and the CMS-1500 claim form. The First Report of Injury Form should be completed when the patient first seeks treatment for a work-related illness or injury, and the physician is responsible for completing this form. The physician’s billing department will also need to submit a CMS-1500 claim form along with the physician’s documentation to the workers’ compensation insurance for reimbursement. The date of injury always needs to be completed on the CMS-1500 and can often be overlooked by billing.
Workers’ compensation insurance will have no deductible or copayment, and all providers must accept the compensation payment as payment in full. Balance billing of patient is prohibited. The state compensation board or commission establishes a schedule of approved fees and can be found on individual state websites.
More information on workers compensation can be found at http://www.dol.gov/general/topic/workcomp