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Workers’ Comp 101 for Medical Providers

Oct 26, 2015 06:12PM ● By MED Magazine

By Danyell Skillman


When an employee is injured on the job, he or she gives notice to the employer who files a claim with the employer’s workers’ compensation carrier. Once a claim is filed, the carrier assigns a claim number to be used when submitting medical claims for payment. The employee is also assigned an adjuster by the carrier who may or may not work in conjunction with a nurse case manager. The nurse case manager can help to coordinate the employee’s care, authorize treatment, and review the employee’s progress until they have recovered to their pre-injury health status.


Below are some tips that medical professionals may find helpful in better understanding workers’ compensation.


▪   The patient provides his or her claim number, the date of injury, and the information required to file a claim to the appropriate payer. The patient’s private health insurance is not billed for services that are covered by workers’ compensation; however, non-work related treatment provided in conjunction with authorized services are billed to the patient’s own insurance.

▪   The adjuster may authorize services from the employee’s regular primary care provider or the employee may be directed to receive medically necessary services from the carrier’s own network of providers.

▪   Each state has its own guidelines for workers’ compensation claim payments. In states that have fee schedules, the schedules function the same as a provider contract. If the provider treats a workers’ compensation patient, the medical bills are reduced according to the fee schedule.

▪   Like other healthcare claims, workers’ compensation claims should be submitted using the CMS-1500 Claim form. Claims may be submitted to the insurance carrier using their Payor ID and submitting the CMS-1500, along with proper records, to the appropriate electronic clearinghouse. When completing the CMS-1500, medical billers fill in the fields that indicate the patient’s condition is work-related, the date of injury, and the date of service. Instead of an insurance ID number, the patient’s claim number is supplied to the payer to ensure that the appropriate injury is being treated and paid for.

▪   When the charges are found to be appropriate, the adjuster reprices the charges in accordance with the state’s fee schedule. Unlike other insurance coverage, medical providers are not allowed to bill patients for the balance between the fee schedule and the full amount of charges submitted. Workers’ compensation insurance does not include co-insurance or co-payments. Instead, providers agree to accept the fee schedule rates as payment in full for services rendered.

▪   Like other healthcare claims that are submitted on paper via the mail, claim turnaround time from submission to payment is typically 30 days. Workers’ compensation medical claims require


greater attention to detail than commercial claims submitted electronically. The CMS-1500 must be completely legible and all fields must be completed including the correct CPT procedure codes, as incorrect information in the wrong fields may delay processing. Additionally, since copies of a provider’s progress notes must accompany each claim form, the copies must be legible, they must be complete, and they must pertain to the codes included on the form. Submitting claims without appropriate documentation will delay prompt payment.

▪   The claims adjuster will need to obtain the current and often prior medical records to best manage the claim. To ensure that treatment is not delayed, it is critical that the requested medical records are sent to the adjuster in a timely manner.

▪   Usually, when a check is issued to pay a medical bill, an explanation of benefits (EOB) form is enclosed with the check. This EOB gives the medical provider the basis for any reduction of the charges as billed. In addition, the EOB lists instructions in the event the medical provider wants to dispute any reductions in payment from what was originally billed. It is important to follow the instructions carefully so there are no delays when requesting a reconsideration.

Some medical providers may not have a lot of experience with workers’ compensation claims, so to answer questions and to resolve any problems, it is best to communicate with the carrier as often as necessary.

 Danyell Skillman is a Claims Supervisor with RAS.