One of the most challenging claims for an ASC billing office to process
are workers' compensation claims. It is equally challenging to provide
universal recommendations to ease the process since workers' compensation
claims regulations vary from state to state. Therefore, the most important
recommendation is to know your specific state rules and regulations for
billing workers' compensation.
While each state processes workers' compensation claims differently,
states generally adhere to one of three categories:
- States that don't follow a fee schedule.
- States with a fixed fee schedule.
- States with a percent-of-charge based fee schedule.
research performed by the Workers' Compensation Research Institute, states
without a fee schedule or a percent-of-charge fee schedule pay more per
case. Regardless of the state and payment methodology, there are key processes
that should be a part of your ASC's best billing practices to ensure
Here are 10 recommendations to improve management of workers' compensation claims.
1. Obtain a complete history of the injury, including date of injury and
any past procedures performed on each workers' compensation patient.
2. Confirm that the scheduled procedure is related to the injury.
3. Verify current contact information for the insurance adjuster assigned
to the patient's case.
4. Confirm the procedures that will be performed and calculate the expected
amount per the payment methodology in your state to ensure your costs
5. If you live in a fee schedule-based state and implants are considered
inclusive to the procedure, obtain a "letter of agreement" from
the adjuster verifying coverage of costs.
6. Ensure all authorizations from the carrier or adjuster are in writing.
Never depend on a verbal authorization.
7. Register with the state workers' compensation board to stay abreast
of the latest rules and regulations regarding changes to policy or payment
8. When updates are posted for upcoming payment changes, perform a reimbursement
analysis to understand the financial impact of each procedure on your facility.
9. In states that base payments on a fee schedule, know your options in the
event that a case is underpaid. Depending on your state, you may be able
to file a lien if the appeals process is unsuccessful. Inform the adjuster
if the case isn’t paid correctly. You can also file a complaint
with your state's department of insurance (department of financial
services), if necessary.
10. Ensure that your ASC's physicians are contracted with as many workers'
compensation carriers as possible. Some states require that providers
and the facility be contracted with each carrier's medical provider
network (i.e., an entity or group of providers set up by an insurer or
self-insured employer to treat workers injured on the job).
Success is in the Details
If your ASC chooses to accept workers' compensation, it is imperative
that you take a careful approach with each and every case. Know your state's
rules and the process to help ensure you receive full payment for every
procedure performed and service provided. Make sure you have a means to
stay informed on regulatory and/or payor rule changes likely to affect
workers' compensation. Working with experienced ASC billers, either
in-house or through an outsourced billing company, can further help reduce
the likelihood of your leaving significant money on the table.
Angela Mattioda (email@example.com) is vice president of revenue
cycle management services for Surgical Notes RCM. Surgical Notes is a
nationwide provider of revenue cycle solutions, including, transcription,
coding, revenue cycle management (RCM), document management and electronic
health record applications for the ASC and surgical hospital markets.
Mattioda oversees the SNBilling
RCM service, the newest component of Surgical Notes' complete end-to-end
revenue cycle solution offering.