Work comp billing

Sandy H

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I have a work comp claim that was was done for a Nebraska Physician and the procedure was done in Nebraska. The insurance company is in Florida. I billed a 95909 (Nerve Conductions) along with a 95886-59 (EMG 2 limbs). They denied claim. They are now saying I need to bill using Florida's work comp codes. I have never heard of doing this before. Is this correct? Almost all of our work comp claims are paid from insurance companies that are located out of state.
 

cgaston

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They are wrong. I had the same problem a few years ago and I bill out of New York. They need to reimburse according to the guidelines of the state where the services were rendered. In NY, the pricing is determined by the zip code where the service was rendered. I found the formula, called the carrier and explained it to a Supervisor (and had to after almost every payment we got from that particular company! :mad: ).

I don't know how it is in NE, but if you can find the formula in the NE WC Fee Schedule you should call the carrier back and offer to send them proof they are wrong (and casually mention that what they are suggesting sounds a bit like fraud to you ;) ). Good luck!
 

mhstrauss

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They are wrong. I had the same problem a few years ago and I bill out of New York. They need to reimburse according to the guidelines of the state where the services were rendered. In NY, the pricing is determined by the zip code where the service was rendered. I found the formula, called the carrier and explained it to a Supervisor (and had to after almost every payment we got from that particular company! :mad: ).

I don't know how it is in NE, but if you can find the formula in the NE WC Fee Schedule you should call the carrier back and offer to send them proof they are wrong (and casually mention that what they are suggesting sounds a bit like fraud to you ;) ). Good luck!

Cgaston, Do you know where this info is documented? I deal with the exact same issue as the OP, we have to change the codes for most of our W/C claims (am in LA, which is based on 2012 CPT, which means using the newer EMG codes, but the older NCV codes). The majority of our claims are within LA, but I have some that are out of state that have to be changed. I understand that the pricing may be based on the state the services are rendered, but I believe the coding must follow the guidelines of the state the payer is in ??:confused:
 

cgaston

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Now I remember!

This happened at my old employer, actually, and after thinking about it I remembered that we copied the out-of-state provider guidelines from the FL WC fee schedule.

Here's a link:

http://www.myfloridacfo.com/Division/WC/pdf/2008HCPRM.pdf


It's on page 12:

c. Out-of-state providers.

(1) Prior to the delivery of medical services, an insurer and provider may mutually agree
upon the amounts of reimbursement for the services; or

a.When a reimbursement agreement is not made, the insurer shall reimburse the out-of-state
provider either the greater of the MRA for the services in Part A, Section XI in
this manual or the maximum reimbursement allowances under the workers’
compensation program in the state where the services are provided.



I am adding that to my bookmarks just in case it happens here. :D
 
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WC pays based on the location of treatment. So if the accident happened in State A, but the treatment took place in State B, then it would be the rules of State B that would apply. Some states have mandatory fee schedules, some have specific guidelines (percentages and so forth), and other (like mine) are the unfortunate ones without any statutes or fee schedules so we get paid UCR. Since you can't balance bill the patient, you're stuck with what you get, unless payment arrangements are made with the payer.

One noteworthy piece of information, sometimes WC payers will access and use the payment schedule of a contracted company (contracted with the facility) and try to get a discount like that. We have it happen all the time where they go through a contracted network, and if the contracted rate is too high, they pay what they want to anyway (in a UCR situation). The only way we ever get paid the proper network amount is by going through our contacts at whichever network is being utilized and they force the WC payer to pay properly.

If your state has a fee schedule or otherwise, I envy you.
 
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