Other Issues Impacting Reimbursement

Crossing State Lines

Fee Schedules

Billing Summary

Occupational health presents a special challenge to the billing and coding specialist. While many rules for private insurance billing apply, the imposition of state-specific regulations and federal guidelines demands specialized knowledge and requires additional paperwork in the reimbursement process. This article addresses both the unique and routine aspects of occupational insurance management specific to the billing process.

While the goal of any physician is to diagnose and treat the patient, the occupational medicine practitioner has an added objective: to return the patient-employee to work as soon as possible. This goal is shared by the employer and, in most cases, by the employee. Both the practitioner and the employer are now involved in the reimbursement process: the employer to authorize treatment that the practitioner will provide for reimbursement. Involvement of the employer in the billing process is unique to the field of occupational health; no private insurance is concerned with a third party involvement except as it absolves them from payment responsibility.

Also unique to occupational health billing is the amount of paperwork required to ensure reimbursement; while this may vary by state, the paper trail still exists nationwide. Furthermore, state and federal regulations may govern reporting aspects of injuries, unlike the private sector. Coding, both procedural and diagnostic, comes in large part from nationally used texts, but with possible state-specific additions and/or deletions mandated by the state’s workers’ compensation board.

Billing and Reporting

Management of the case in occupational medicine is vital from the first day of treatment, not only for optimal return to work but also to ensure optimal reimbursement of the provider. Ideally, each office/clinic setting has an employee whose function is to obtain authorizations from the employer to treat injured workers. A worker may arrive with a medical service order for treatment or the clinic may have a standing order on file in the client’s profile. In the absence of a standing or written order, telephone authorization or a fax request, with the name and title of the person who issued it, should be obtained and kept in the chart. In addition to verifying the treatment, authorization establishes the relationship between the employer and the provider as allies in the treatment of the patient-employee.

Following the injured worker’s initial visit, a report is generated, signed by the provider, and attached to (or made a part of) the billing form. This report is generally referred to as a First Treatment Report and is required by most states. Although reporting times vary greatly among the states, it is in the best interests of all parties to submit the report as soon as possible. Depending on state rules, copies of the First Report generally go to the state and the employer, in addition to the workers’ comp carrier. This report is a legal document, since it is a part of the patient’s medical record. In some states, failure to file a First Treatment Report can be a misdemeanor.

Timely filing is as important in occupational health as it is in all insurance billing to expedite claim authorization and ultimately bill payment. Establishing the injured worker’s diagnosis affects future treatment and provides the employer with information to assess the need for possible future treatment authorizations. In most states, the employer also submits a report to the workers’ comp carrier, and the two reports together (employer/provider) open the case for the injured worker.

After filing the claim, a tracking procedure should ensure prompt payment from the workers’ compensation carrier. It is in the interest of the provider to be sure that the employer’s report is submitted, since failure to do this will affect authorization of the case, and thus payment.

If a temporary disability has occurred, the worker may need further visits and/or rehabilitative treatment. Status reports may now be required to keep the carrier apprised of the worker’s condition. States vary in their forms and filing requirements, and failure to comply will affect reimbursement. A final report may be required when the worker is discharged, particularly if there is a permanent disability. Again, the forms and formats will vary from state to state.

Medical Records Issues

The concept of confidentiality, inherent in medical records, takes a unique turn in occupational medicine. Many states allow workers’ compensation carriers unlimited access to injured workers’ records that pertain to work-related injuries, and some states extend this privilege to employers. However, other rules, such as the Americans with Disabilities Act and the ACOEM Code of Ethics apply, and care must be taken to ensure that released records deal with only the pertinent industrial injury.

Copies of all reports, authorizations, etc., must be kept in the patient’s chart, and at this point the individual office/clinic has a decision to make: should separate charts be kept for a patient who is seen both privately and also for an occupational injury/illness, or should all records be kept in one chart that is divided into sections? Financial records should follow suit: two separate accounts for the same patient, or all records in one account? Certainly there is merit in each case, but the higher likelihood of records requests and court subpoenas renders the work-related information more vulnerable to copying. Separating private from industrial medical records, should both be in one chart, can be time-consuming and can increase the possibility of overlooking records.

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Subsequent Treatment

Injured workers may be scheduled for follow-up appointments as part of an ongoing treatment plan. Unrelated complaints should not be seen at the same visit. A separate appointment should be made, the next day if necessary, to avoid incorrect billing. Some states also restrict different appointments on the same day, even if both visits deal with the same date of injury, e.g., an office visit and a physical therapy session. Both of these scenarios can have a real effect on reimbursement and should be monitored by the case manager and scheduler when necessary.

Vocational rehabilitation is always a possibility when an employee is injured and, here again, case management is necessary. The medical practitioner, employer, insurance carrier, and physical therapists need to work in accord toward returning the patient-employee to the workplace.

Occupational health practices may include therapists as part of the team, or the employer may have in-house therapists. In other cases, the practitioner may refer the patient to an outside rehabilitation center. The authorization process now becomes the responsibility of the physical therapist, who needs to develop a treatment plan particular to the injured worker. The insurance carrier and/or the employer may require status reports. Whether the treatment plan utilizes work hardening or an ergonomic worksite evaluation, the object is to return the employee to the job.

Billing for services needs to continue in a timely manner throughout the treatment and rehabilitation period, with appropriate forms filed to indicate what is being done and by whom. In some states, reimbursement may be delayed if reports are not appended to claim forms. Tracking of claims, by verbal or written inquiries to insurance carriers, is a necessary feature of occupational health. It is not abnormal to submit claims twice, due to incomplete or incorrect information, lack of authorization for treatment, or delays by the carrier.

Other Issues Impacting Reimbursement

Many states require bill reviews to monitor correct reimbursement. In some states the state agency itself conducts the review, while in other states the workers’ comp insurance carriers utilize an outside review company for analysis of claims and pricing before releasing payment to the practitioners. While there are generally time constraints placed on the carriers, a review company may issue an explanation of benefits before the carrier sends a check, or the opposite may occur: a check may arrive and must be held until the review company sends the explanation of benefits. Technically, the reimbursement has arrived within the allotted time period, but the practitioner doesn’t have access to the funds. If the practitioner’s office has a case manager, information (reports sent to carriers, explanations of benefits sent to offices) can be exchanged with carriers, sometimes electronically or by fax, which can help speed the reimbursement process.

Increasingly, computers and the Internet are changing the way payers are being billed, including occupational health claims. While the majority of private carriers now encourage electronic claims, occupational health carriers are just beginning to accept computer-transmitted data. Part of the problem is the inordinate amount of paperwork needed in addition to, or in place of, the HCFA-1500 universal claim form. However, universal data processing codes and electronic injury forms have been developed and are being used, even required, in more and more states.

For those states still utilizing paper forms, the HCFA-1500 is generally the required billing form. Whether information is input to a computer to be printed, or is typed, data entry is critical. The top portion of the form contains employer/employee information, such as the employee’s name, Social Security number, insurance carrier, and ID number. The bottom portion must give the date of injury, hospitalization dates, pertinent authorization numbers, billing codes, fees, and practitioner/hospital data.

The importance of a good data entry person is frequently overlooked when considering reimbursement, and this is a mistake. Large numbers of delays and denials result from data entry errors. Claims management should include (and can be handled by) the data entry employee. This employee, when trained in current occupational health regulations, is of inestimable value to any practice or clinic. State manuals should be made available to data entry specialists, and seminars dealing with state occupational medicine regulations should be attended regularly by anyone who does data entry in this field.

The reports mentioned throughout this article are usually required by workers’ comp carriers, if not by law, to assess progress of the injured worker and ensure payment. It may be possible to charge for the reports (with the exception of the First Treatment Report) in addition to any office visits and/or treatments, except in the state of Washington, where providers are reimbursed for completion and filing of this report. Some reports are billable as a single charge per report, while others are billable by the page. Billing and reimbursement are generally stipulated by state workers’ comp laws.

Crossing State Lines

Problems arise when a worker is employed in one state but is injured while working in another state. The regulations that apply are those from the state where the worker was hired. It is therefore imperative that the biller contact the insurance carrier in the employer’s state, as well as the employer. The biller must know if the fees, billing codes, and reporting requirements are the same or different. In particular, use of the HCFA-1500 claim form may be different (some states require a First Treatment Report statement on the HCFA-1500 rather than in a separate report).

If an injured worker chooses to seek care in another state, he/she may be held personally responsible for any charges incurred. In that case, pre-authorization needs to be obtained before any treatment is given, and the worker must be informed if he/she will be liable for any charges.

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Fee Schedules

No discussion of occupational health would be complete without mention of the fee schedule. Development and adoption of a standard fee schedule varies by state. Some states have set a maximum reimbursement rate; some use the Medicare RBRVS (Resource Based Relative Value System) as a base, adding a certain percentage. Whatever the schedule, practitioners, hospitals, and suppliers are expected to take payment from the carrier as payment in full, and not balance bill the worker. Offices and clinics deal with the fee schedules in different ways: some build the actual fees into an Accounts Receivable program so that no adjustment is necessary unless a denial has been received; others use their private patient fee schedule and take the adjustment when payment is received.

Managed care carriers may stipulate an additional adjustment on top of the fee schedule. This can be a matter of negotiation with the carrier, and should be carefully considered by any practitioner/clinic contemplating a managed care contract for occupational medicine. Once the contract is signed, these adjustments need to be carefully tracked.

State fee schedules are generally one of two types: one that is based on a percentage of the provider’s usual and customary fees, or one which uses a relative value scale. The latter uses five-digit codes, usually in CPT format, and assigns each code a value. A conversion factor then assigns a dollar amount to codes by the type of service performed (office visit, surgery, anesthesia, etc.). When the state reviews conversion factors, the billing codes are updated at the same time to reflect new procedures.

Care must be taken when tracking reimbursement: charges may be denied for spurious reasons, and need to be appealed with pertinent documentation; office visit codes may be "downcoded" (assigned to a lower level) and should be appealed with documentation that supports the level billed. It may be necessary to submit operative reports with surgical procedures, again to support the charges billed. An up-to-date and accurate SuperBill or charge ticket can help eliminate incorrect billing code choices.

Billing Summary

Occupational health insurance requires routine, methodical tracking during the entire billing process, similar to all insurance work. A thorough knowledge of state regulations, plus the volume of periodically required reports, renders this type of payment and reimbursement unique. Having an individual whose specific job assignment is to acquire authorizations, understand the complex forms, deal with fee schedules and contracts, and comprehend differing reimbursements and adjustments can make a difference to the bottom line. Equally important is the relationship among practitioner, employer, and carrier, working as a team to diagnose, treat, and return the patient-employee to work.

Look for Part 2 in the Winter issue of the Occupational Health Tracker. 

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