How Doctors Are Paid For Treating Workers’ Comp Claimants
Getting medical bills paid has become very complex. Billing for treating injured workers is no exception. This article offers guidelines in how you are paid for treating injured workers. You may wish to give this information to your billing office.
The form required for billing is either DCBS Form UB-92 or Form HCFA-1500, “Health Insurance Claim Form.” You should have copies of these forms.
AWAITING ACCEPTANCE OR DENIAL
The Workers’ Compensation carrier (“insurer”) has to accept or deny the worker’s claim within 90 days. No money will be sent to you until the insurer has decided to accept. While awaiting the insurer’s acceptance or denial of the claim, the best ways to protect yourself are:
• Send correct and complete bills to the carrier/insurer in a timely manner.
• Note that doctors may not take any collection action against an injured worker so long as the claim is in litigation.
When your patient’s claim is accepted, the insurer may not be required to pay your bill in full. The insurer is only required to pay the usual and customary fee for the medical service provided, according to the schedule (OAR 436-009-000 1, et seq.) issued by the Department of Consumer & Business Services (DCBS).
You DO NOT need to send a copy of the bill to your patient (“the worker”), UNLESS he requests in willing that you do so. If your patient’s injury is accepted, you MAY NOT bill your patient for the unpaid portions of your billed services.
When your patient’s injury has been accepted, be sure to get a copy of the letter of acceptance so you know the condition which the insurer has accepted (the accepted condition”). This is important for at least two reasons: First, you cannot expect to be paid by the comp insurer for treating anything which is not part of the “accepted condition;” and Second, if the accepted condition does not include conditions which you believe were caused by the work incident, then you can notify your patient.
This is important since your patient has a right to request acceptance of any condition related to the work exposure which the insurer omitted from the original acceptance. The insurer must consider such requests; and, if medically and legally valid, must issue an “amended acceptance” accordingly. This will help to insure that your bills are paid properly.
What if the insurer is not paying your bills on an accepted claim?
Here are some things you can do:
• Contact the claims examiner and request payment.
• Keep a precise log of all calls, including names, times and contents of the discussion.
• Call the DCBS Medical Review Unit at (503) 945-7849. They can be very effective.
• If the bill is not paid within 45 days of billing on an accepted claim, write to DCBS, Medical Review Unit, 21 Labor & Industries Building, Salem, OR 973 10, and request review of the matter.
If your patient’s work injury claim is denied, you can bill the health care insurer, 9 any. Health insurers are required by statute to pay in these circumstances.
Also, KEEP BILLING THE WORKERS’COMP INSURER EVEN AFTER A DENIAL since your patient may appeal. On appeal, if your patient obtains a reversal, your bills will be paid as for an accepted claim. Or, your patient’s claim may be settled on a “Disputed Claim Settlement’ (“DCS”) basis.
When a DCS is entered, the insurer is required to pay a portion of any related bill they have in their possession. The insurer must pay up to 50% of the audited value of your bills. However, the maximum total amount allowed for medical bills is 40% of the net present value of the total settlement (“net settlement”). If 50% of the audited value of the medical services exceeds 40% of the net settlement, payment is pro-rated among all medical providers.
For example, if the net settlement is $10,000, the maximum amount available to pay medical bills is $4,000 (40% of $10,000). So, if the audited value (not the billed amount) of the medical providers’ bills is $9,000, the medical providers will not get 50% of this amount, since that would total $4,500. Instead, each medical provider will be paid its pro-rated share of the $4,000.
It is critical that you keep billing the comp insurer, since only the bills that the insurer has received will he paid under a DCS!
In DCS cases, you may recover from your patient the balance of the amount owing for your services. The “amount owing” refers to 50% of the audited value of your bills, not the total billed amount.
Of course, when a claim is denied and the denial has become final, you may bill your patient for unpaid bills.
This article was prepared by Robert F. Webber.