Pinnacol Processes for Workers Compensation

Transcription

1 Pinnacol Processes for Workers Compensation WORKERS COMPENSATION BASICS COURSE // MODULE 8 OF 8 Pinnacol Processes for Workers Compensation // Page 1

2 Pinnacol Processes Module 8 Objectives Upon completion, participants should be able to: Outline the Pinnacol processes for key activities Determine the rationale and requirements for IMEs and DIMEs as they relate to MMI Examine specific Pinnacol billing requirements and policies Slide 3 Authorizations for payment Prior authorization for payment is not necessary for diagnostic testing, in-network referrals or treatments when consistent with the Medical Treatment Guidelines issued by the DOWC. Rule 16 is the reference for prior authorizations. Slide 4 - Prior authorization for payment is required When a prescribed service exceeds the recommended limitations in the guidelines When prior authorization is required for a specific service in the guidelines When a service is identified in the fee schedule as requiring prior authorization for payment When a prescribed service is not identified in the fee schedule Slide 5 - Medical records submissions The Division of Workers' Compensation has strict requirements for the timely maintenance and provision of medical records. Send every piece of paperwork related to your patients' medical care as soon as possible. That includes correspondence, records and everything associated with the IW's treatment. Medical Records FAX: (outside of Metro Denver) Slide 6 - Medical records releases See DOWC interpretive bulletin #9: Slide 7 Independent medical exam (IME) An IME usually involves a request for the IW to be examined by a doctor who had not previously seen the IW although an IME can be performed by a physician who has previously treated the IW. This independent review may be warranted for any number of reasons including: The date of MMI The impairment rating Slide 8 - Division IME If there is a dispute between the IW and the employer concerning the MMI date or the impairment rating provided by the ATP, and the parties wish to bring this dispute before a judge, the law requires the parties first obtain a DIME. Slide 9 DIME Established to reduce litigation and to provide an alternative way to address disputes Performed by a Level II-accredited physician Pinnacol Processes for Workers Compensation // Page 2

3 If parties cannot agree upon a physician, the Division will select an examiner based on an application submitted by the party who objects to the rating or statement of MMI. Slide 10 - Return to work PCP must respond within 2 business days of receipt of a modified duty or return to work request The letter must be signed only by a physician who has treated the IW. If modified duty is not available or the employer is unsure if a modified duty position is possible, contact the Pinnacol claims rep for help. Slide 11 - Provider communication When addressing modified duty or full duty return-to-work, provider communication, whether provided on a WC164 form or office dictation, should include IW s work status, including effective date Specific work restrictions The date of the IW s next scheduled appointment For all forms, include the provider s name, clinic name, date of report, address and phone number. Slide 12 MMI Maximum medical improvement is the point in time when Any impairment resulting from the injury has become stable, and No further treatment is reasonable expected to improve the condition Patients may require treatment after MMI to maintain their functional status. The provider should indicate whether continuing care is needed in the maintenance care after MMI section on the WC164 form. Slide 13 - Billing requirements Submit bills for approved health care services to Pinnacol Do not directly bill or receive payment from an IW or employer insured by Pinnacol unless the claim has been denied by Pinnacol or the employer fails to file the claim. Slide 14 Reimbursement Pinnacol has 30 days to process bills (DOWC rule). Providers should redact the Social Security number on all medical bills; the claim number serves as the worker s identifier. Do not resubmit claims or bills within the first 30 days after filing. The second submission will be rejected as a duplicate. The claims filing deadline is 120 days after the date of service. Pinnacol Processes for Workers Compensation // Page 3

4 Slide 15 - DOWC Medical Fee Schedule Pinnacol reimburses at rates established by the Colorado DOWC fee schedule (Rule 18) minus any contractual discount in effect at the time services are provided. Rule 18-1 identifies the current editions of publications to be referenced for billing codes and can be accessed at the DOWC website. Slide 16 Reconsideration SelectNet providers can file appeals online and access claim number and billing information Out of network providers can contact the bill processor directly at the phone number on the EOB Fax additional documentation to , Attn: Medical Payments Team. Fax coversheets are available on the pinnacol.com site on the appeals page. Slide 17 - Bills and coding Rule 18 governs the maximum allowable reimbursement The medical fee schedule based on RBRVS, set by Medicare and paid on prior year rates. Z codes are specific only to Colorado and created by DOWC. CPT codes based on the prior year. Slide 18 - Billing for initial visit Pinnacol will pay for reasonable and necessary medical treatment by the authorized treating physician and any referrals. The IW does not pay a copay or deductible. Slide 19 - Billing for initial visit For injuries with lost time (over 3 working days or shifts) and permanent medical impairment is anticipated Pinnacol must send a First Report of Injury (FROI) form to DOWC. Pinnacol has 20 days to admit or deny compensability after the Division receives the notice of claim. Slide 20 - Payment for visits on denied claims Pinnacol is not responsible if liability is denied. Providers must check for eligibility and status. Pinnacol will pay for initial visit if Pinnacol arranges for the IW to be seen the provider; OR The policyholder has sent the IW to their designated provider Pinnacol Processes for Workers Compensation // Page 4

5 Slide 21 - Billing on a CMS1500 Box 31 must contain the signature or printed name and professional credential of the provider who provided the service. Slide 22 - Billing on a UB-04 Hospitals providers must complete all fields mandated by Medicare. Box 62 (insurance group number) must contain the Pinnacol claim number Box 82 (attending physician) must contain the physician, physician assistant, or nurse practitioner s name and Colorado license number Slide 23 - Billing for rehab and DME Pinnacol contracts: Outpatient physical, occupational and speech rehabilitation Orthotic and prosthetic care Durable medical equipment Home health care Billing for rehab and DME is based on contractual requirements and cannot be assumed to be paid direct to the physician or clinic without a contract. Slide 24 - General pharmacy billing tips Pinnacol will only pay for the in-house dispensing of prescription or over-the-counter medications in emergent situations. After the initial 14-day emergency supply, for all other situations, medications should be supplied by a registered pharmacy in Pinnacol's pharmacy benefit program, Optum. Contact the Pinnacol claims team for an out-of-network referral if travel for the IW exceeds 15 miles. Slide 25 - Billing for modalities Rule 18 limits payments to two different modalities per visit, per day, per discipline. Slide 26 - General billing tips Original invoices for items must be forwarded. Pinnacol requires the original manufacturers invoice to determine the true per-item cost. Slide 27 Acknowledgement Letters sent to IW and employer Claims rep contacts employer and IW within 24 hours for early intervention and compensability determination The employer will be asked for the wage report Pinnacol will explain the benefits to the injured worker Pinnacol Processes for Workers Compensation // Page 5

6 Slide 28 - Claim investigation Importance of medical history Can help determine causality Allows apportionment for pre-existing conditions Sets baseline, conditions and expectations that effect the healing process Slide 29 - Payment dispute resolution process Rules 16 and 18: Submit a medical billing dispute resolution intake form to the DOWC Medical Policy Unit (MPU). Return by fax, encrypted or mail to the MPU. Reviewed within 30 days and communication will continue until a determination is made The form and all supporting documentation can be submitted to the MPU by fax at , encrypted , or mail to: Division of Workers' Compensation Medical Policy Unit th Street, Suite 400 Denver, CO Typical review time is within 30 days and parties will be notified in writing once the case is closed. References SelectNet Provider Manual Exhibit C Medical records fax cover sheet DOWC interpretive bulletin: Director s interpretations of issues impacting the Colorado workers compensation system: Release of Medical Information (May 22, 2002) HIPAA & Colorado Workers Compensation (May 19, 2003; revised Feb 2006) Medical Billing Dispute Resolution Intake Form Handouts: Tips for E&M Coding-level Documentation Prior Authorization versus Notifications No Claim on File Pinnacol Processes for Workers Compensation // Page 6

7 Review T or F: The rating and/or the date of MMI can be challenged by requesting an IME or DIME. T or F: An IME involves a request for the IW to be examined by a doctor who has previously seen the IW. The Pinnacol claims rep contacts the employee within 24 hours of an injury report and will not discuss: a) Early intervention b) Compensability c) The injured worker s benefits d) The wage reports T or F: PCP must respond within three business days of receipt of a modified duty or return to work request. T or F: The modified duty or return to work request letter must be signed only by a physician who has treated the IW. How many days does Pinnacol have to admit or deny compensability after receiving the First Report of Injury? a) Two days b) Five days c) Seven days d) Twenty days Under what circumstance can PCPs bill Pinnacol for medication dispensed in their offices? a) The nearest pharmacy is over ten miles away b) The PCP dispenses only a thirty-day supply of meds c) The PCP dispenses a one-time 14-day supply in an emergent situation d) None of the above Rule 18 limits payments to different modalities per visit, per day, per discipline. a) Two b) Three c) Four T or F: For the first report of injury, lost time is more than three missed scheduled work shifts. Pinnacol Processes for Workers Compensation // Page 7

8 Pinnacol has days to process bills for payment according to the DOWC. a) 14 b) 30 c) 45 d) 60 T or F Prior authorization is required, when A prescribed service exceeds the recommended limitations in the guidelines; When authorization is required for a specific service in the guidelines; The service is identified in the fee schedule as requiring prior authorization for payment; or A prescribed service is not identified in the fee schedule. Pinnacol Processes for Workers Compensation // Page 8