Medical Billing

Billing medical services for injured workers covered by workers' compensation involves unique processes and requirements that are different from other types of insurance. By following these best practices, medical billers and healthcare providers can streamline the billing process, ensuring timely and accurate payments while minimizing delays and denials.

Gather Complete Information about the Payer

Medical providers should capture the responsible payer’s information upfront, especially where multiple providers may be involved. Always capture:

• Name of the insurance carrier (or third-party administrator paying the claim)
• Name, mailing address, email address, and phone number of the adjuster
• Contact information of a liaison or supervisor

Medical case managers cannot authorize nor deny treatment.  The carrier should be billed, not the medical case manager.

At every office visit, the provider should verify the contact information for the adjuster and any change in the claim status.

Authorization for Payment Only Comes from the Carrier

Do not misinterpret the medical director’s order of medical necessity as authorization to proceed with treatment. You still need to obtain authorization for payment from the insurance carrier.

Do Not Bill the Patient

The bill needs to be sent to the correct payer, not the patient. In workers’ compensation cases, the injured worker is not responsible for medical bills. Billers must obtain the correct payer information directly from the workers' compensation insurance carrier or the patient's employer. 

Submit Medical Documentation with Bills

Include the office visit notes related to the service(s) rendered. “They can’t pay you unless they know what you did.” The office notes help justify the services rendered and how long you spend with the patient so healthcare providers can be paid correctly.

Services shall be billed on industry standard billing forms, their electronic equivalent, or their official replacement forms: 

• UB-04
• CMS-1450
• CMS-1500
• ADA form (for dental providers)
• NCPDP WC/PC UCF (for pharmacies)

Electronic billing submissions shall comply with the Bureau’s rules for electronic billing.

Follow Timely Filing Guidelines

Billers need to meet all deadlines for submitting initial bills. Workers' comp follows Medicare guidelines, so be familiar with those timeframes to avoid non-payment due to tardiness.

Understand the Fee Schedule & Coding

The workers' compensation fee schedule establishes a maximum allowable reimbursement amounts for medical services delivered to Tennessee injured workers.

• For Tennessee claims, refer to our Medical Fee Schedule Rate Tables. This resource outlines the maximum allowable rates for specific service codes.
• For claims outside Tennessee, contact the insurance adjuster assigned to the case to verify the applicable fee schedule.

Understanding these fee schedules helps ensure your billing processes and codes align with approved rates, minimizing the risk of denials.

Review Existing Contracts

Be aware of how prior contracts that may be used for workers' compensation including commercial contracts and those inherited from other insurers, could impact your reimbursements. Understand any requirements for opting out of such contracts.

How to Handle Denials

If initial bills are denied, carefully re-check all information before resubmitting the bill to the payer. Contact the original payer or designated liaisons courteously to resolve issues. Maintaining positive relationships supports future business.

Case Studies

These real-life scenarios highlight common mistakes that can delay or deny workers' compensation claims. Let's see how proactive steps by medical providers can ensure smooth billing and timely reimbursement.

Case Study 1: Incomplete Payer Information

A physician (selected from the employer's panel) sees an injured worker in their office, but the patient provides incomplete insurance information. The office bills the patient directly. This results in the patient receiving a bill they should not be responsible for, as workers' compensation is required to cover the medical expenses. To avoid this issue, the physician's office should gather the payer details from the employer, such as the insurance carrier, claim adjuster, and any authorization information. This ensures that the bill will be submitted correctly to the appropriate workers' compensation payer.

Case Study 2: Lack of Medical Records Submitted

A physician provides treatment to an injured worker but does not submit the associated medical records along with the bill. The workers' compensation payer denies the claim, stating that additional documentation is required to justify the level of service billed. To prevent this, the physician's office should make sure to include the relevant office visit notes or other medical records detailing the care provided when submitting the bill. This supports the services billed.

Conclusion

Adhering to these best practices streamlines the billing process while helping medical providers receive appropriate and timely reimbursement for services provided to injured workers in Tennessee. If you have any other questions, contact us at wc.info@tn.gov.