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Workers comp or health insurance

  1. Default Workers comp or health insurance
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    I am working on an appeal for a patient. Here is a little background, patient fell and hurt his back at work, went to get checked out and they asked about abnormal movements. He was referred to a specialist where he was diagnosed with Huntington's disease. He now comes to my office for treatment of the disease. I have billed his insurance but they are not paying for the visits due to it being related to workers comp. Should this be billed to workers comp or should I continue with the appeal?

  2. #2
    worst case, send to WC and let them deny as not work related
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

  3. #3
    Harrisburg Pennsylvania Chapter
    Unless the Huntington's was caused by the work injury, the health insurance is responsible. This will probably require a call to the insurance company to discuss the circumstances. The patient may have to call, as well, to explain the situation and update the COB.

  4. #4
    Upper Saddle River, NJ
    Default Dx Confirmation Required - Reason for Accident
    Medical Billing
    Since the HD may be inherited, WC may not be responsible for this issue. HD is typically inherited from a person's parents, although up to 10% of cases are due to a new mutation. Your provider will need to determine the accurate Dx and if the incident occurred due to HD the Health Ins. may be responsible. This issue must also have direct input from your patient due to the complexity. Only by getting the patient involved can get some movement on this issue with the Health Plan. Providers do not have as many rights with the Health Plans as the patient does and therefore the most effective way is to get your patient to legally assign his/her rights to your provider for any appeals/inquiries/etc. I would submit to WC but you will need to not get timed out with the Health Plan for an appeal. Good Luck.
    Last edited by KN; 10-30-2018 at 08:27 AM.

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