Billing for Worker’s Compensation

Basics of Worker’s Compensation

Worker’s compensation, commonly known as worker’s comp, is a type of insurance that covers the treatment of injuries occurring on the job. Employers typically purchase commercial worker’s comp policies directly, although some states administer these policies. Medical billers must therefore remain aware of the worker’s comp policies for their state, including their limitations and differences from other types of medical insurance.

Worker’s comp claims are still processed manually, although most other health insurance claims are now processed automatically. The primary reason for this difference is that worker’s comp requires greater oversight to ensure the claimant has a work-related injury and receives injury-specific treatment. The billing procedure for worker’s comp consists of several phases, including filing the claim, patient treatment, and processing the claim.

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It’s important to note that while the policyholder is usually the patient in the group health world, the employer is the subscriber in the worker’s comp sector. Also, what is normally termed an explanation of benefits (EOB) in a patient-insured claim is an explanation of review (EOR) in a worker’s comp case.  And instead of identifying a claim through your regular healthcare identification number, you use a case file or claim number in its place.

Billing for Worker’s Compensation

Worker’s compensation billing can be confusing at times. Knowing a few background guidelines and rules can help you along the way. Worker’s 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 Worker’s compensation coverage to meet minimum standards.

Billing for worker’s compensation claims can differ from state to state, sometimes making it problematic. Knowing your state’s regulations, which are established by your state commission, will keep your practice in compliance. However, there is general nationwide billing information for worker’s compensation claims that does help keep billing somewhat uniform.

It’s important to utilize the correct forms when billing for worker’s 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 worker’s compensation insurance for reimbursement. The date of injury always needs to be completed on the CMS-1500 and can often be overlooked by billing.

Worker’s compensation insurance will have no deductible or co-payment, and all providers must accept the compensation payment as payment in full. Balance billing of patients is prohibited. The state compensation board or commission establishes a schedule of approved fees and can be found on individual state websites.

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Denials and Appeals

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 worker’s compensation insurance be billed for the service and the primary payer has already paid the provider, the worker’s compensation insurance will need to be billed. If the worker’s compensation claim is denied, an appeal will need to be initiated. The reimbursement paid by the primary payer must be returned.

Billing may be denied by an insurer for other reasons:

  • No claim on file
  • Injured worker not an employee of the company
  • Treatment not causally related to report the work injury
  • No documentation provided, required to process payment

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