What Options Do You Have If Patient’s Claim Is Denied?

A physician from Klamath Falls asked us recently what options are available to a physician if a Workers’ Compensation case is denied by the carrier.

The answer depends on what kind of denial: Has the carrier denied the claim for medical services on the basis that your patient’s claim is not compensable? Or is the denial made on the basis that your services are not reasonable and necessary? So, first you need to determine the reason they are denying payment on your bills. We will consider each situation in turn.

If your treatment is denied because it is not reasonable and necessary, it may be because your treatment has been considered excessive or for other administrative reasons. If you disagree with the denial, you may appeal this decision to the Workers’ Compensation Medical Director. This procedure does not involve lawyers. For disputes about fees, providers must request review on Form 440-2330 (“Medical Fee Dispute Resolution Request”) within 90 days from the time you knew or should have known about the dispute.

If your dispute concerns medical issues such as the appropriateness of treatment, palliative care, experimental treatment, MCO disputes or medical rules violations, your request must be submitted on Form 440-2842. For copies of forms and more information, you may call the Medical Review Unit at (503) 945-7849.

If your patient’s Workers’ Comp claim has been denied and your patient disagrees with the denial, your patient must appeal it. The appeal must be made to the Workers’ Compensation Board within 60 days of the denial. The patient has a right to be represented by an attorney at the hearing at no cost for attorney fees to the patient/worker. Costs incurred (such as special medical reports to prove the case) are the responsibility of the patient. The patient should have an attorney because there will be an attorney representing the insurer/employer.

If the comp carrier (or self-insured employer) knows you have treated the worker relative to a claim, you should receive written notice of your patient’s denial.

Here is some information and direction concerning medical treatment and billing for your patients’ Workers’ Comp claims which have been denied in whole or in part:

If you receive notice your claim for medical services has been denied, you may submit medical reports and bills to the injured worker’s health insurer. This, of course, includes public-assistance programs (OMAP, Oregon Health Plan and Medicaid) as well as private health insurers. The health insurance provider will be entitled to reimbursement from the Workers’ Comp carrier if the Workers’ Comp carrier is later found to be responsible. The health insurance carrier may require the worker to sign a trust agreement.

If the injured worker has no health coverage, you may bill the patient; but you may not take any collection action until the issues of compensability of medical services have been resolved. Therefore, if the only source of payment is the worker, the physician must use his conscience with regard to treatment.

Disputed Claim Settlements (DCS): If there has been a denial of your patient’s injury claim, be sure to send bills and records to the comp carrier or self-insured employer. This is important, because if the claim settles without a hearing as a disputed claim settlement (“DCS”), the comp carrier (or self-insured employer) is required to pay 50% of all medical bills that they have received, up to a limit of 40% of the total settlement. However, this is only for medical services related to the comp claim that would have been compensable under the comp law). NOTE: The law does not clearly state whether a physician may look to his patient for unpaid balance of charges, after receiving the one-half (or “relative value scale”) payment after a disputed claim settlement.

“Accepted Claim” Issues: Billing problems may also arise where there has been a partial denial or no denial of your patient’s injury claim. It is important for you to be aware of exactly what conditions have been “accepted” under the work injury. Ask your patient to show you the Notice of Claim Acceptance. You may not get paid if you do not identify what you are treating as the injury/condition which has been accepted. For example, if a “back strain” has been accepted, but the x-rays also show degenerative disc disease, be clear in your chart notes what your are treating. If you believe additional conditions other than what has been accepted are work-related, you should advise your patient to seek legal advice concerning the steps to take to get his entire injury properly covered.

Your patient may have claimed (and you may be treating) more than one injury/condition resulting from a work incident.

The carrier may accept one or more parts and deny others. This will result in a “Notice of Acceptance” and a “Notice of a Partial Denial.”

Also, it is now necessary to state if the work injury/exposure is the major cause of the need for treatment, if it has “combined with” a pre-existing condition (see accompanying article, this issue).

Your awareness of exactly what has been accepted is important for another reason. If you realize that the work-related condition you are treating involves more than what has been accepted, you would be doing your patient a favor to immediately suggest that he/she look into requesting an expansion of his/her accepted condition to take these new developments into account. Again, you will be paid only for treatment of the accepted condition(s).

Robert F. Webber, Robert L. Chapman
and Arthur W. Stevens, III collaborated on this article.