Historically, resolving workers’ compensation claims has required a very manual process. Providers have struggled to balance this laborious process and other demands.
Challenge 1: Workers’ compensation insurance is not like a commercial or government policy. There is not a universal eligibility tool to verify coverage, effective dates, and claim number to allow a quick and clean claim submission. The injury has to be determined to have been caused at work to be covered by workers’ compensation insurance, and not all employers choose to carry or use the policies they have in place.
Many hospitals and health systems outsource workers’ compensation claim resolution because of the effort required to verify coverage and gather the necessary information to process the claims. Documents often have to be faxed or mailed, claims must be researched, and electronic filing of the claims is the exception. Even when electronic claims are permitted, you may still have to provide corresponding documentation to the carrier via separate means. It can be very confusing to navigate these processes payer by payer and state to state.
Some employers will choose to pay out of pocket instead of filing claims because they don’t want their premiums to go up. Settling outside of your workers’ compensation carrier is not always approved of, and depending on the state you are in, it could be against state rules. Some states require the filing of the injury. All states have a Workers’ Compensation or Labor Bureau that manages their employers’ workers’ compensation cases. Employer, carrier, insurance – all these terms can be interchangeable, and ultimately “they” are the party responsible for the bill.
Challenge 2: Workers’ compensation is state-specific. Finding resources and guides can be a time-consuming process as a provider attempts to resolve a workers’ compensation claim.
For example, in the state of Ohio, if a patient says “I work for ABC Manufacturing Company,” one could use the Ohio Bureau of Workers’ Compensation database to search for the workers’ compensation carrier associated with that company. One could also discover if there is a claim open on the patient’s behalf and submit a claim UB and medical documentation. Many states do not have a similar website so all research must be done by making phone calls.
If you are a hospital or health system in a border city, the complexity increases. You must first determine where the claim was filed and who is responsible for the claim and follow the rules of the proper state. These state rules determine the amount of your reimbursement. Most states have at least annual changes to rules, fee schedules, etc., and you must keep up with those rules and adjust your processes accordingly.
Challenge 3: Denials. Workers’ compensation insurance companies will fight these claims for a variety of reasons – did the injury happen on the job? Was the employee working or simply ‘at’ work? What is the responsibility of the employer? Often a patient feels the employer is responsible, and the employer does not agree.
Should a dispute arise and the employer not be determined to be responsible, the bill would then fall to the employee. The claim could be billed to the employee’s health insurance – once again, creating complexities. It would be easy for a health insurance company to deny the claim due to the lack of timely filing. Assisting the patient in getting their medical claims paid creates a positive patient experience and ultimately gets the claim paid for the provider.
As you can see, there are many challenges and complexities involved in the workers’ compensation claims process.