1/11/2012. Pre-Test Question #1. Basic Workers Compensation for Medical Office Staff

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1 Basic Workers Compensation for Medical Office Staff Presented by: Regina Schwartz Health Care Specialist Texas Dept of Insurance -Division of Workers Compensation 2012 This presentation is for educational purposes only and is not a substitute for the Law and Division Rules Pre-Test Question #1 How do I know if the patient s employer has workers compensation coverage? 1) Ask the patient 2) Verify coverage with the Division 3) There is no way to know 4) 1 & 2 3 1

2 Pre-Test Question #2 Does preauthorization guarantee payment? 1) Yes, the carrier must always pay for the service that was preauthorized. 2) No, the carrier can deny reimbursement for lack of medical necessity. 3) No, the carrier can deny payment for compensability reasons. 4) All of the above. 4 Pre-Test Question #3 What are the risks associated with billing the employer? 1) You cannot pursue Division dispute resolution if the employer does not pay. 2) None. The employer always pays more than the carrier does. 3) You cannot bill the carrier if the employer does not pay. 5 Pre-Test Question #4 What happens if I miss filing deadlines? 1) The carrier can deny payment for untimely filing. 2) You miss your opportunity to request dispute resolution from the Division. 3) None of the above. 4) 1 & 2 6 2

3 Two databases with a total of over questions were reviewed to determine common billing and reimbursement problems and to recommended solutions Calls and s 85% from health care providers/facilities or their staff 15% are other, including insurance company representatives, attorneys, etc. 8 The insurance carrier didn t pay the bill. Why? Missed Dead lines Incorrect billing codes/modifiers No preauthorization Not Medically necessary Not compensable Payment made per FGs 9 3

4 10 Tips for Health Care Providers and Staff Tip #1 -Identify a WC claim Tip #2 -Understand the use of the ODG and when to request preauthorization Tip #3 -Keep up with Medicare Tip #4-Understand your responsibilities and risks when billing employer Tip #5 -Know and meet your deadlines 11 Tip #1 Identify a Workers Compensation Patient What you need to know and why 12 4

5 What are the risks in not knowing the patient is a workers compensation claimant? Missed billing deadline Billed the wrong carrier/patient Didn t get preauthorization 13 What You Need to Know Did the injury happen on the job? When? Does the employer have workers compensation coverage? Who is the workers compensation insurance carrier? Is the medical coverage handled through a certified workers compensation network? Does the health care provider have a contract with the network? 14 Does the employer have workers compensation coverage? Except for public employers and as otherwise provided by law, only employers who elect to obtain workers compensation coverage are subject to the Labor Code 15 5

6 How do I know if the patient s employer has workers compensation coverage? 17 Workers' Compensation Insurance Coverage Data on the TDI-DWC Website Texas Subscribers Texas Subscribers download file Listing of Certified Self-Insurers Texas Non-subscribers download file Dynamic files 6

7 Call the DWC Insurance Coverage Department , opt. 6 In Austin: , opt Tip #2 Understand the Use of the Treatment Guidelines and When to Request Preauthorization 7

8 Entitlement to Medical Benefits The injured employee is entitled to all health care reasonably required (medically necessary) that: Cures or relieves the effects naturally resulting from the compensableinjury; Promotes recovery; or Enhances the ability of the employee to return to or retain employment. 22 Medical services are presumed reasonably required (medically necessary)when they are: Provided in accordance with the Division s adopted treatment guidelines, and Provided in accordance with prospective, concurrent, or retrospective review processes. 23 Treatment Guidelines 24 8

9 Reimbursement policies and guidelines; treatment guidelines and protocols Requires the commissioner to adopt treatment guidelines that are: Evidence-based Scientifically valid Outcome-focused Designed to reduce excessive or inappropriate medical care Safeguard necessary medical care 25 Purpose of Treatment Guidelines To assure injured employees are receiving the most appropriate medical treatment, established by evidence-based medical standards, optimizing the employees returnwork outcomes Treatment Guidelines Official Disability Guidelines Treatment in Workers' Comp (ODG) *excluding the return to work pathways Published by Work Loss Data Institute

10 Treatment Guidelines Health care providers shall provide treatment in accordance with the current edition of the ODG Health care provided in accordance with the ODG is presumed to be reasonable and reasonably required 28 The Official Disability Guidelines (ODG) Provides a list of diagnoses and indicates the corresponding medical treatment for that diagnosis. Treatment is: Recommended Not recommended Under study 29 ODG Procedure Summaries Bed rest Not recommended for any low back condition in the absence of unstable spinal fractures Behavioral treatment Recommended as option for patients with chronic low back pain and delayed recover Workloss 30 Data Institute 10

11 Prospective and Concurrent Review Preauthorization Preauthorization is the prospective review of medical treatment and services for medical necessity Treatments and services provided in a medical emergency do not require preauthorization 32 Preauthorization Approved treatment is not subject to retrospective review of medical necessity Carrier can not deny payment for medical necessity reasons 33 11

12 Concurrent Review Concurrent review is the extension of previously preauthorized treatments and services Treatments and services provided in a medical emergency do not require concurrent review 34 Concurrent Review Approved treatment is not subject to retrospective review of medical necessity Carrier can not deny payment for medical necessity reasons 35 Is a preauthorization or concurrent review approval a guarantee of payment? 12

13 An approval is not a guarantee of payment. The carrier can deny payment for compensability, extent of injury, or liability issues. Read the fine print The approval must include, a notice of any unresolved dispute regarding the denial of compensability or liability or an unresolved dispute of extent of or relatedness to the compensable injury. 37 Voluntary Certification of Health Care The carrier is liable for treatments and services that are agreed upon The agreement must be documented Can not deny payment retrospectively for medical necessity or compensability Denial of a request is not subject to dispute resolution 38 Section Carrier Liability The insurance carrier is not liable for those specified treatments and services requiring preauthorization or concurrent review unless approval is sought by the claimant or health care provider and either obtained from the insurance carrier or ordered by the commissioner

14 What medical services require preauthorization and concurrent review? Rule Types of non-emergency medical services that require preauthorization and concurrent review. Not a list of CPT codes. 40 ODG and Preauthorization Rule ODG & Preauthorization Requirements Treatments and services that exceed or are not addressed by the Commissioner's adopted treatment guidelinesor protocols and are not contained in a treatment plan preauthorized by the carrier

15 ODG & Preauthorization Requirements Preauthorization is required if the diagnosis or treatment is not addressed by the ODG is not recommended by the ODG exceeds the ODG in frequency duration 43 ODG & Preauthorization Requirements If the diagnosis and treatment is in the ODG, and is recommended by the ODG Then preauthorization is required only for treatments and services on the Division s preauthorization list in Treatment / Preauthorization Decisions 45 15

16 Tip #3 Stay Current with Changes from Centers for Medicare and Medicaid Services (CMS) Labor Code Mandates that the Division establish medical policies and guidelines standard to other health care delivery systems, and Mandates the use of most current CMS weights, values, measures and payment policies. 47 Medicare policy changes By Division rule, automatically become applicable to the Texas workers compensation system on or after the effective date of the Medicare program component, or after the effective date or the adoption date of the revised component, whichever is later 16

17 A good resource for the workers compensation biller is the person who bills for Medicare. What would Medicare do? Medicare Biller Workers Compensation Biller External Resources (CMS and MACs) CMS for National policies, and Non-DWC specific coding and billing issues: see the CMS website at Professional services (covers most professional services): see the TrailBlazer Health website at External Resources (CMS and MACs) Durable medical equipment: see the Cigna Government Services website at Dental, home health and some DME: see the Texas Medicaid and Healthcare Partnership website at 17

18 Tip #4 Understand and Manage the Benefits and Risks of Submitting the Bill for Medical Services to the Employer What are the benefits to the health care provider for billing the employer? Rule (j) The health care provider may elect to bill the injured employee's employer if the employer has indicated a willingness to pay the medical bill(s)

19 Rule (j) When a health care provider elects to submit medical bills to an employer, the health care provider waives, for the duration of the election period, the rights to: prompt payment interest for delayed payment; and medical dispute resolution 55 Rule (j) When a health care provider bills the employer, the health care provider: Is required submit an information copy of the bill to the insurance carrier, which indicates that the information copy is not a request for payment. Must bill in accordance with the Division's fee guidelines and use the required billing forms/formats. 56 Rule (j) A health care provider is notallowed to submit a medical bill to an employer for charges an insurance carrier has reduced, denied or disputed

20 What are the risks associated with billing the employer? Risks associated with billing the employer: Employer will pay an unacceptable amount and there is no fee dispute resolution process available to the health care provider. Claim issues regarding compensability, extent of injury, liability or medical necessity may arise and there is no dispute resolution process available to the health care provider. 59 Risks associated with billing the employer: Employer will not pay or forward bill to carrier until after 95 calendar days from date of service. This may result in the health care provider forfeiting the right to payment from the insurance carrier

21 Risks associated with billing the employer: Billing the employer does not change the requirements for preauthorization. Failure to get preauthorization when required may result in the health care provider forfeiting the right to payment from the insurance carrier. 61 Considerations: The decision to bill the employer rests with the health care provider. Be very selective as to which employers are billed for workers compensation services. Set a time limit for payment from employer. After this time limit, send a bill to the insurance carrier requesting payment. 62 Tip #5 Know and Meet Your Deadlines 21

22 What happens if I miss filing deadlines? Problems caused by missing deadlines Billing and Reimbursement Forfeiture of right to reimbursement Incorrect reimbursement Preauthorization Delays in getting medical service Forms Performance Based Oversight audit 65 Summary of Billing and Reimbursement Deadlines 22

23 Health care providers submission a complete medical bill Rule Deadline: No later than 95 calendar days after the date of service 67 Health care providers submission a complete medical bill Only exceptions to the 95 day rule: bills that were timely submitted to group, accident, and health insurance HMO, or wrong WC carrier within 95 calendar days of date of service, or the commissioner determines that the failure to submit the bill timely resulted from a catastrophic event that substantially interfered with the normal business operations of the provider. 68 Carriers request for additional documentation Rule Deadline: Not later than the 45th calendar day after receipt of the medical bill 69 23

24 Health care providers response to a carriers request for additional documentation Rule Deadline: Not later than 15 calendar days after receipt of request for additional documentation Medical documentation rule: Carriers return of an incomplete medical bill Rule Deadline: Within 30 calendar days after the insurance carrier receives the medical bill The return of an incomplete bill completes required actions by the carrier, but does not stop the clock for the 95 calendar day billing deadline of the health care provider Complete medical bill is defined in Rule Clean Claim requirements are in Rule Carriers payment of a complete medical bill Rule Deadline to audit: Provide notice not later than45 calendar days after receipt of medical bill; then pay 85% of contracted amount, fee guideline amount, or fair and reasonable amount Must complete audit within 160 calendar days after receipt of complete medical bill

25 Carriers final action (pay, reduce or deny) after review of a complete medical bill Rule Deadline for final action: Not later than 45 calendar days after receipt of complete medical bill Deadline is not extended as a result of a pending request for additional documentation. 73 Health care providers request for reconsideration of a medical bill that was reduced or denied Rule: Deadline: Not later than the 11 th month from date of service Health care provider cannot request reconsideration until carrier has taken final action on bill or, the health care provider has not received an explanation of benefits within 50 days from submitting the medical bill. 74 Carriers response to a request for reconsideration of a medical bill that was reduced or denied Rule Deadline if request is incomplete: Return within 7 calendar days of receiving request for reconsideration Deadline if request is complete: Reply within 21 calendar days of receiving request for reconsideration 75 25

26 Summary of Deadlines for Dispute Resolution (Non-Network) There are three dispute paths Compensability, Extent, and Liability Examples: ANSI Codes 214, 218 and 219 Medical Necessity Examples: ANSI Codes 50 and 216 All other (mostly fee disputes) Examples: ANSI Codes 97 and There are three dispute paths Dispute tracks can be identified from information on the Explanation of Benefits EOB is required to contain sufficient detail to explain factual basis of action (Rule 133.3) 78 26

27 79 Summary of Filing Deadlines for the Preauthorization Process Carrier to respond to a request for preauthorization Rule Deadline: 3 working days after receipt of request, except one working day for a request for an extension of previously approved services for concurrent review

28 Health care provider to request reconsideration for a preauthorization that was denied Rule Deadline: 15 working days of denial If reconsideration is not requested timely, a request for preauthorization for the same health care shall only be resubmitted when the requestor provides objective clinical documentation to support a substantial change in the employee's medical condition 82 Carrier to respond to a request reconsideration for a preauthorization that was denied Rule Deadline: 5 working days of receipt of a request for reconsideration of a denied request for preauthorization except 3 working days of denied concurrent review. 83 Health care provider to request an independent review organization if reconsideration is denied Rule Deadline: Not later than 45 th calendar day after receipt of denial of request for reconsideration 84 28

29 Carrier to notify the Health and Workers' Compensation Network Certification and Quality Assurance Division of the request for an independent review organization Rule Deadline: 1 working day 85 Independent review organization to provide decision of preauthorization dispute Rule Deadline: (1) for life-threatening conditions, no later than eight days after the IRO receipt of the dispute; (2) for preauthorization and concurrent medical necessity disputes, no later than the 20th day after the IRO receipt of the dispute 86 Summary of Filing Deadlines in Texas Workers Compensation for Reports: DWC form 73 and DWC form 69 29

30 Rule Health care provider to file DWC form 73, Work Status Report Deadlines: Copy to the injured employee at the time of the examination Copy to the carrier and the employer not later than the end of the 2 nd working day after the date of examination 88 Health care provider to file DWC form 73, Work Status Report Rule: Deadlines: Copies to carrier, employer, and injured employee within 7 calendar days of the day of receipt of: functional job descriptions from the employer listing available modified duty positions that the employer is able to offer the employee as a Bona Fide Offers of Employment a required medical examination doctor's Work Status Report that indicates that the employee can return to work with or without restrictions. 89 Health care provider to file DWC form 69, Report of Medical Evaluation Rule Deadline: no later than the 7th working day after the later of: date of the certifying examination; or the receipt of all of the medical information required by rule

31 What we can do for you Verify Rule requirements Explain processes Lead you to resources 91 Resources CMS for National policies, and Non-DWC specific coding and billing issues: see the CMS website at Professional services (covers most professional services): see the TrailBlazer Health website at Resources Durable medical equipment: see the Cigna Government Services website at Dental, home health and some DME: see the Texas Medicaid and Healthcare Partnership website at 31

32 Resources Subscribe to CMS and TrailBlazer listserv appropriate to your medical practice Subscribe to for updates from TDI-DWC TDI-DWC Health Care Provider Web Page

33 What we cannot do for you Code your bill Guarantee payment Solve dispute outside of established processes 97 How you can be involved Rule Writing Process The Division welcomes and encourages stakeholder input to ensure meaningful consideration of all issues and perspectives in the development of the rules effecting the agency s designated doctor program New Rules Process 1. Texas Legislature passes laws to provide guidance to TDI-DWC. 2. TDI-DWC staff drafts informalrules based on guidance in law. 3. Informal draft rules are published for public comment by system stakeholders 4. Comments from system stakeholders are carefully reviewed and considered by TDI-DWC staff. The comments are used in preparing the rules for formal proposal for public comment

34 New Rules Process 5. New and amended rules are formally proposed for public comment by system stakeholders. 6. Comments from system stakeholders are carefully reviewed and considered by TDI-DWC staff. The comments are used in preparing the rules for adoption. 7. New and amended rules are adoptedby the Commissioner of Workers Compensation. 8. New and amended rules are implementedin the Texas workers compensation system

35 Post-Test Question #1 How do I know if the patient s employer has workers compensation coverage? 1) Ask the patient 2) Verify coverage with the Division 3) There is no way to know 4) 1 & Post-Test Question #2 Does preauthorization guarantee payment? 1) Yes, the carrier must always pay for the service that was preauthorized. 2) No, the carrier can deny reimbursement for lack of medical necessity. 3) No, the carrier can deny payment for compensability reasons. 4) All of the above. 104 Post-Test Question #3 What are the risks associated with billing the employer? 1) You cannot pursue Division dispute resolution if the employer does not pay. 2) None. The employer always pays more than the carrier does. 3) You cannot bill the carrier if the employer does not pay

36 Post-Test Question #4 What happens if I miss filing deadlines? 1) The carrier can deny payment for untimely filing. 2) You miss your opportunity to request dispute resolution from the Division. 3) None of the above. 4) 1 & Q & A 36