SOP
      Back to home
      1. Help Center
      2. SOP

      Workers' Compensation Guide V2.3

      Workers' Compensation FAQ

      Background: 

      Workers' compensation is a state-mandated insurance program that provides benefits to employees who suffer job-related injuries and illnesses. Each state has its own laws and programs for workers' compensation. The federal government also has a separate workers' comp program, mostly for federal employees. For up-to-date information on workers' comp in your state, contact your state's workers' compensation office. (You can find links to the appropriate office in your state on the State Workers' Compensation Officials page of the U.S. Department of Labor's website.) In general, an employee with a work-related illness or injury can get workers' compensation benefits regardless of who was at fault—the employee, the employer, a coworker, a customer, or some other third party.

      An injured worker may choose any physician or medical provider authorized by the Workers’ Compensation Board (WCB) to provide medical care. Most times though the WC insurance company case manager will choose the physician depending on specialty, contract status and location.

      Workers’ Compensation Basics:

      Employer/ Employee

      1. The forms required vary based on the state in which the accident/ injury occurred. Please see Schedule A for links to all state billing requirements.
        1. Example: Nevada requires the below form from the patient and another from the treating provider (b).
          1. C-1: If an injury or occupational disease (OD) arises out of and in the course of employment, you must provide written notice to your employer as soon as practicable, but no later than 7 days after the accident or OD. Your employer shall maintain a sufficient supply of the required forms.  NV: http://dir.nv.gov/uploadedFiles/dirnvgov/content/WCS/c-1.pdf
          2. C-4 (This is completed upon initial visit with provider): If medical treatment is sought, the form C-4 is available at the place of initial treatment. A completed "Claim for Compensation" (Form C-4) must be filed within 90 days after an accident or OD. The treating physician or chiropractor must, within 3 working days after treatment, complete and mail to the employer, the employer's insurer and third-party administrator, the Claim for Compensation. NV: http://dir.nv.gov/uploadedFiles/dirnvgov/content/WCS/c-4.pdf
      2. If an injured worker requires medical treatment for their on-the-job injury or OD, they may be required to select a physician or chiropractor from a list provided by your workers’ compensation insurer, if it has contracted with an Organization for Managed Care (MCO) or Preferred Provider Organization (PPO) or providers of health care. If their employer has not entered into a contract with an MCO or PPO, they may select a physician or chiropractor from the Panel of Physicians and Chiropractors. Any medical costs related to their industrial injury or OD will be paid by the (A Third-Party Administrator (TPA) may also do this in lieu of the injured worker.)
      3. An injured worker should not pay a fee directly to the doctor or medical provider.
      4. An injured worker may be required to sign a form from the medical provider guaranteeing payment for a disallowed claim if the Carrier or the employer disputes the claim. An injured worker must follow doctor’s instructions to speed recovery.
      5. An injured worker must also follow up with their employer by providing specifics as to when they will be able to return to work.
      6. An injured worker must notify their employer of any changes in their ability to work or their work status because of the injury.
      7. An injured worker must attend independent medical examinations (IME) when requested.
      8. An injured worker must attend hearings when notified to appear.
      9. An injured worker may be eligible for vocational rehabilitation services if they are unable to return to the job due to a permanent physical impairment or permanent restrictions because of their injury or occupational disease.
      10. An injured worker may be able to reopen their claim if their condition worsens after claim closure.

      Employers’ Responsibilities:

      1. Required forms depend on the state in which the injury took place. For details on the state you work working with please see Schedule A for links to billing manual for each state
        1. Example of physician form for Nevada: C-3: When an employee is injured due to a work-related accident or becomes ill due to exposure, the employer or its designee must provide the injured worker with the “Claimant Information Packet” as soon as possible. The employer or its designee must note on the C-2 form that the packet was given to the injured worker. NV: http://dir.nv.gov/uploadedFiles/dirnvgov/content/WCS/c-3.pdf
        2. Update employee status when needed. Employees must provide specifics as to when they will be able to return to work.

      Physicians’ Responsibilities:

      For a complete list of what is required of physicians (primary and specialty care) for each state please see Schedule A link for the state you are working with.

      1. Upon initial visit with injured worker:
        1. Collect all details including employer information, adjuster name, adjuster phone number, claims address, timely filing limits, date of injury and authorization (if needed) to see and treat patient (this includes notification of any testing required to properly evaluate the injured worker), Payer where claims are submitted to, payer address, phone number, etc. and all patient demographics
        2. Patient and physician fill out any necessary/ required forms
        3. Submit claims and medical records including any necessary forms timely

      Specialist Care:

      1. The specialists’ office staff must gather case manager contact information and reach out to coordinate plan of care, prior authorization, etc. the specialist must receive all prior medical records from primary care physician / prior specialist group & copies of any required forms (Schedule A) prior to or at the time of the appointment.
      2. The specialist will need to obtain WRITTEN Authorization from the Insurance TPA case manager or adjuster for services to be rendered (do not take just a verbal)
        1. Treatment
        2. Consultation
        3. Diagnostic Testing
        4. Elective hospitalization
        5. Any surgery which is to be performed under circumstances other than an emergency; or any elective procedure

      Specialized Evaluations (upon request of Worker’s Compensation carrier):

      Typically for a special evaluation (like the ones listed below) the insurance company selects an appropriately qualified physician and provides an authorization letter to the physician requesting such services.

      1.  Temporary Total Disability (TTD): Provider has certified that injured worker is unable to work for a period of at least 5 consecutive days, or 5 cumulative days in a 20-day period, or places restrictions on the injured worker that their employer does not accommodate, the injured worker may then be entitled to TTD compensation
      2. Temporary Partial Disability (TPD): If the wage the injured worker receives upon reemployment is less than the compensation for TTD to which they are entitled, the insurer may be required to pay the injured worker TPD compensation to make up the difference. TPD can only be paid for a maximum of 24 months
      3. Permanent Partial Disability (PPD): When the injured workers’ medical condition is stable and there is an indication of a PPD as a result of their injury or OD, within 30 days, their insurer must arrange for an evaluation by a rating physician or chiropractor to determine the degree of their PPD. The amount of their PPD award depends on the date of injury, the results of the PPD evaluation and the injured workers’ age and wage.
      4. Permanent Total Disability (PTD): If the injured worker is medically certified by a treating physician or chiropractor as permanently and totally disabled and have been granted a PTD status by their insurer, they are entitled to receive monthly benefits not to exceed 66 2/3% of their average monthly wage. The amount of their PTD payments is subject to reduction if they previously received a PPD award.
      5. Independent Medical Evaluation (IME): An independent medical examination (IME) occurs when a doctor/physical therapist/chiropractor/psychologist/neuropsychologist who has not previously been involved in a person's care examines an individual and provides their independent evaluation of the workers’ injury, recovery, etc

      Other Keywords Defined:

      • Case manager: This individual helps the injured worker obtain the medical care that he or she needs. They serve as a liaison between all parties involved in the WC claim including physicians, the injured worker, the employer, the insurance company and the billing company. They also provide treatment authorization and coordinate doctor visits.
      • Claim adjuster: The claims adjuster is responsible for contacting the injured worker once the claim has been opened. They receive all necessary employer forms, employee statement, and medical records. They ultimately decide if the injury was work related or not and notify the employer, employee, and health care providers of their determination. The adjuster basically opens and closes the workers’ compensation file. The adjuster evaluates the claims and forwards them to another department for payment. The adjuster maintains contact with the employee and health-care professionals regarding status of the injury and treatment plans. *They also can push a claim through for payment if needed.
      • Prior authorization: This is the process of obtaining pre-certification prior to the injured worker receiving services. The purpose of the prior authorization function is for the nurse case manager to determine WC claim status, coverage, medical necessity, location and appropriateness of services.
      • Jopari: This is a clearinghouse used by Health Prime to submit Workers’ Compensation and personal injury claims that require attachments.
      • EWC: This is a prefix used in Health Prime on insurance carriers that have been identified as Workers’ Compensation carriers. Note that not all are marked with this prefix, so advisors will be responsible for knowing which payers to provide in the cases submitted for work.
      • Case rate: This is a pricing method in which a flat amount, often a per diem rate, covers a defined group of procedures, services or range of dates of services. It may be used in services such as obstetrics, cardiovascular surgery or hospitalization. Practices must have Insurance Contracts defining these case rates with agreed upon codes and reimbursement. When billing these services, the “trigger” code or Case Rate CPT code (and applicable units and modifiers) must be billed in conjunction with any other codes for the insurance company claims system to recognize the contractual rate. If billing a trigger code in conjunction with other services, the incidental codes should be adjusted (except for patient responsibilities) when payment for the trigger code is made.
      • Balance Billing: Healthcare providers are not allowed to bill patients for the balance between the fee schedule and the full amount of charges submitted. Workers' comp insurance does not normally include co-insurance or co-payments. Instead, providers agree to accept the fee schedule rates as payment in full.

      Billing Responsibilities:

      1. Ensure we send complete claims to Workers’ Compensation which includes:
        1. All standard personal info (including SSN)
        2. Claim #
        3. Employer’s Name
        4. Date of Injury (DOI)
        5. Body part / Diagnostic code
        6. correct claims address
        7. Referring physician
        8. Medical records pertaining to date of service submitted (any related testing)

      Charge Processing:

      1. Any charges received without corresponding medical records are put in Review tab and billing task created for practice
      2. Health Prime does not allow submission of Worker’s Compensation claims that are missing medical records.
      3. There are times where Health Prime may receive charges from the practice and when claims are submitted to the medical insurance, and there is a Work comp or auto injury they are aware of, the claim will be denied stating "The claim is accident or injury related and it needs to be filed with Workers’ Compensation carrier”. When this happens Health Prime team will create a billing task for updated demo/ policy info from the practice.

      Billing Challenges & Resolutions:

      1. Credentialing: If a practice or physician is not in network with the Workers’ Compensation carrier typically they will request a W9 document for the practice. For Health Prime these are collected during onboarding, so you will need to review Salesforce documents for a copy. If one is not found, you will create one if there is a TAF on file allowing us to use the owners signature.
      2. Providers should possess a Department of Labor/ Worker’s Compensation Provider ID number (if applicable) many states require that this number be listed on the claim in a specific field. Please check the guidelines for the state you are working with in Schedule A. This ID number may also be required to check claims status.
      3. Claims should always be submitted through Jopari clearinghouse (Electronic Workers' Compensation and Auto Insurance Companies) even if submitting paper Claims
        1. Health Prime must ensure that medical records related to the date of service including any testing is attached in the desktop application. For instructions on how to attach records visit Special Claim Instructions in the encounter SOP.  If possible, confirmation of receipt of the claims should be obtained especially if timely filing limit is short.
      4. Payment turnaround
        1. healthcare claims that are submitted on paper via the mail, claim turnaround time from submission to payment is typically 45 days. Workers ‘compensation healthcare claims require greater attention to detail than commercial claims submitted electronically. The CMS-1500 must be completely legible and all fields must be completed with the claim form aligned with the printer. Misaligned claims may prevent claims from being legibly scanned upon receipt, and correct information in the wrong fields may delay processing. Additionally, since copies of a provider’s progress notes must accompany each claim form, the copies must be legible, they must be complete, and they must pertain to the codes included on the CMS 1500 Submitting claims without appropriate documentation will delay prompt payment.
      5. Common Claims Denials: Claim scrubbing prior to submission can be done to avoid the following billing errors:
        1. Billing for the wrong body part
        2. Billing for different injury with multiple body parts; cannot be proven that this is tied to original injury; doctor may have to technically explain why this new procedure is part of the existing case by writing medical necessity letter.
        3. If claim is closed or case was settled with claimant. In this case the claim becomes the responsibility of the patient. Transfer the balance(s) to the patient and bill them as the responsible party UNLESS there is an attorney on file. If the attorney is no longer working the case as closed/settled patient is ultimately responsible. (this is the ONLY instance where you can bill an injured employee for a work injury)
        4. Missing WC indicator or DOI (date of injury) on claims: create a billing task to gain this if not found in record.
      6. Working with an adjuster / Managed Care Organization (MCO)
        1. Adjuster typically assigned to an employer
          1. Typically, one adjuster / MCO
          2. Having the wrong adjuster / MCO on file
          3. Having the wrong TPA
        2. Required forms, authorizations, referrals, procedures need to be followed perfectly per the payer guidelines and workers’ compensation guidelines for the state. If physician is contracted with HMO WC payers it is highly recommended that we attempt to obtain a copy of the provider contract so that we can assist with requirements

      Claim Follow Up:

      All claim follow up should be done via a telephone call to the claim adjuster orvia portal if available. Many times a voicemail (or multiple) must be left for a call back. Notate claim with all follow up attempts.

      If you are not receiving the desired communication from the adjuster or WC agent that you need to status the claims you are working on you will need to submit an appeal letter.

      Another option is to try to get the injured worker (Patient) to assist with getting in touch with the claims adjuster. Sometimes the patient will have more success than we do when trying to reach their adjuster.  

      REMEMBER: We cannot bill a patient that has balances pending a WC Carrier that has an active WC case open for the patient. It is unlawful. The only time you can bill the patient for WC injury balances is if the patient was seen AFTER the WC Case was closed or if the reason for the visit was NOT related to their work comp injury. 

      Please do not email the adjuster or workers' compensation carrier with claim details