Workers’ compensation claims are typically only 3-5% of a hospital’s revenue. However, they require a disproportionate amount time and expertise to process due to their complexity. Improper handling can quickly cost the hospital time and revenue. Why are these claims so difficult? On the surface they look similar to any other insurance covered treatment. But, there are specific differences that can lead to complications. Let’s examine three reasons.
First, coverage may be unknown. In Georgia, employers with at least three employees are required to carry workers’ compensation insurance. Therefore, most working citizens are covered. However, most employees do not know specific information about their employer’s coverage. A patient seeking treatment for a work-related injury may not know benefit details or which insurer underwrites the insurance coverage. Since patients rarely know the details of their employer’s coverage, it becomes the responsibility of the hospital staff to research coverage to properly file claims.
To make this process easier, the Georgia State Board of Workers’ Compensation and South Carolina Workers’ Compensation Commission provide an online coverage verification tool. Simply select the date of the reported incident and input the employer’s name. The verification tool will provide the name of the insurance carrier, policy number, coverage date, and employer location. The health provider is responsible for verifying coverage either before or at the time of treatment. A complete verification of coverage should be requested and provided in writing or via fax to the health provider.
Second, workers’ compensation claims require more documentation than regular insurance. Most states require key portions of the medical record to be submitted with the bill. The amount of information a medical provider discloses is limited to the amount needed to process the claim. These ambiguous guidelines mean that claim documentation may be extensive or minimal depending on the claim. The insurer may request documentation on admission history, physicals, emergency department report, discharge summary, and more.
The documentation for workers’ compensation claims is different than individual insurance because workers’ compensation insurance is working on behalf of the employer. The documentation helps the employer and insurer determine causality of the claim. HIPAA requirements protect an injured employee’s full medical history, but do allow for medical records of work-related injuries to be shared without additional patient consent.
Third, like most state-regulated industries, the rules governing workers’ compensation insurance are subject to changes, updates and additional mandated processes. An annual review of legislation changes to workers’ compensation rules, forms and deadlines will help your staff stay on top of these shifting processes. Luckily for hospitals, most of the legislative changes to workers compensation insurance affect the employer more often than health providers.
However, hospitals can get caught in the middle if an employer is noncompliant or unaware of new guidelines. For this reason, it is in the hospital’s best interest to be up to date on legislation concerning workers’ compensation law and fee schedule changes. To make the issue more complicated, workers’ compensation policy differs from state to state. Unlike Medicare, which is a federal policy, there is a different workers’ compensation policy in place in each state. In fact, workers’ compensation is even more varied than Medicaid from state to state. For example, Ohio has a single payer system while states like Georgia and California are comprised of hundreds of commercial workers’ compensation insurers. Some states mandate electronic billing for some or all parts of the workers’ compensation revenue cycle. Other states only accept paper records and billing. Understanding the nuances of these varied systems is important for all hospitals. It is critically important for specialty hospitals and hospitals located on or near state lines.
There are several options to help hospitals navigate the complex structure of workers’ compensation policies. One is to utilize a law firm. Many law firms specialize or have associates who specialize in workers’ compensation law. It may be obvious to engage an attorney when addressing complicated situations such as appeals and denials. Law firms can also be of help in submitting complicated claims and addressing issues before they are denied. While law firms face the same challenges of developing and maintaining expertise in workers’ compensation law as hospital administrators, going this route will free up hospital staff for other, more productive tasks. Additionally, a skilled law firm may be able to collect more revenue than in-house staff. There are, of course, fees involved when engaging a law firm. Hospitals should carefully weigh the costs and benefits of legal representation when considering this option.
Another option would be to engage a consulting firm such as Argos Health. A consulting firm pursues claim resolutions on behalf of their client much the same way as a law firm. In addition, Argos Health is a full-service solution that resolves cases in a timely manner to help hospitals as well as patients. Argos Health works with medical providers and their administrative staff to streamline operations and complex processes for more accurate claim reimbursement outcomes. Argos Health specialists are claim-resolution experts who can help navigate complex state regulations across the country. Their work helps to create an effective and seamless claim process that can improve patient satisfaction.