Workers’ Compensation Quick Tips for ER Physician Groups

• Be aware that two different entities are often at play when it comes to your workers’ comp claim. The workers’ comp carrier/adjuster is the one who investigates the incident itself and determines liability/compensability. The bill review company is the entity that pays the actual bills.

• If you’ve received a workers’ compensability/liability denial (meaning they’ve deemed the illness/injury to not be related to employment), then the decision was likely made by the adjuster. If you’ve received any other type of denial or have not received a response, the issue is likely with the bill review company.
• The most common reason for lack of response (or requests for additional information/documents) is that the bill review company has not received or scanned in documents properly for review. This is especially common with ER billing—given that this type of visit generates two bills. Carriers will often bundle all of your documents together, causing them to request medical records that you’ve already sent, or to deny receipt of one of the two bills altogether. In order to prevent this delay,
• it is best to submit your ER billing in separate envelopes—each with its own copy of the medical records. There may be additional postage expenses, but in the long run, it will save you time and effort and assure the bills are paid timely.

• Pay attention to timely filing statutes, which can be as little as 90 days from the date of service. If you feel that the claim was denied for timely unfairly (such as the patient or the employer not filing or providing you with claim info in time), the adjuster may be able to waive time and get your claim paid. The bill review company will almost never waive timely for you.

• Texas Mutual uses a “Workwell Texas” Network, and may not cover treatment at a non-network facility unless it is immediately following the injury and/or is life-threatening. Follow-up visits may not be covered!
• The State Office of Risk Management in Texas (SORM) and ESIS/Chubb require specific license information in certain boxes of claim forms, and in the following format:

• The Department of Labor requires that you obtain a provider ID that is specific to Department of Labor and is not the same as your NPI! This ID needs to be in certain boxes, as follows:

Department of Insurance/DOI: Keep your applicable state laws in mind, especially when it comes to billing the patient!: For example: in Texas—even in the instance of a compensability denial—you are not allowed to bill the patient until the claim has been adjudicated through the Texas Department of Insurance Division of Workers Compensation (TDI/DWC). This is the case even if you are not disputing the denial itself! See the below helpful links for instructions and documents related to proper procedures:

• We have a dedicated staff that specifically handles workers compensation claims.
• We will facilitate between our clients and insurance carriers to assure we have the proper information and that everything is submitted timely and accurately from the beginning.
• We will then follow up on the accounts to monitor for any issues, delays, or denials.
• We are specially trained to be aware of different carrier requirements and state laws.
• We communicate directly with both facility and patient regarding questions about the process.