Workers' Compensation Doesn't Have to Be a Headache

Article excerpt

Here's how to lighten the paperwork and handle the demands of malingering patients.

It took two years and an appeals-court hearing for a California doctor to receive the $1,345 owed him by a workers' compensation carrier.

All along, he'd been cooperative, sending the insurer copies of his patient's chart notes. Then the carrier denied payment, ruling the care unnecessary. An agreed-upon third-party medical examiner determined that the doctor's care had, in fact, been necessary. But that wasn't evident from the chart notes. Why? No one could read his handwriting.

During the appeals process, the doctor learned one of the universal truths of workers' compensation: It matters how you convey information to the carrier. Not only couldn't the claims adjuster read the charts, but the chart notes weren't even required in the first place. All the doctor was supposed to provide was an easy-to-read, check-the-box status form.

"This shows what inattention to detail can do," says Linda Frappia, president of CompRite, a Santa Ana, Calif.-based workers' compensation consulting firm. "If you play by the rules, you will be paid. But you have to know the rules."

Learning workers' compensation rules is like learning Medicare's: They're confusing, and you must deal with a cumbersome bureaucracy. But, as with Medicare, you can't afford to be oblivious.

Don't leave it up to your office manager to learn the rules, warns William Fleeson, an occupational medicine specialist in Duluth, Minn., and author of a book on workers' comp. "The physician is ultimately responsible," he says.

Your education should begin with your state's division of workers' compensation, usually found within the department of labor. Purchase a copy of the labor code, which spells out what reports are necessary, what information they should include, and how often they must be filed. "Knowing this will help you avoid taking on uncompensated work," Frappia says.

Here are the questions you need to answer, and the steps you need to take, to avoid being left in insurance limbo.

Is the patient covered by workers' comp?

A well-trained receptionist goes a long way toward avoiding uncompensated work. Have her ask all patients who call for appointments whether they think their injuries or symptoms are work-related. If a patient says Yes, a staffer should call the employer (ask for the human resources department) or the workers' comp carrier (if the patient knows it) for authorization.

Record the name and title of the person providing authorization, and ask for immediate follow-up confirmation in writing, advises Janet McDiarmid, a medical-office manager in Sylacauga, Ala., and former president of the Professional Association of Health Care Office Managers. "If payment is delayed or the claim is disputed, it will be much easier to collect if you can send a copy of a written authorization," she says.

Even if your office gets a green light to file a workers' comp claim, copy information about the patient's regular health insurance as well. If the workers' comp insurer or the employer later refuses to pay, or if it turns out the patient's condition isn't considered work-related, you can start billing the patient's regular health plan immediately. You have up to one year after the date of service to submit a claim.

Likewise, ask patients without private insurance to sign a form saying they agree to pay for care if workers' compensation won't pick up the tab.

Is the injury work-related?

Thorough screening of all patients needs to take place in the exam room as well as at the front desk. Just because a patient doesn't connect an injury with his work doesn't mean you shouldn't. "Doctors should know what their patients' jobs are," Frappia says. "Then, when a patient comes in with complaints, you'll have a better awareness of whether the injury is job-related."

Why is this important? …