Texas Workers’ Compensation
Tips for Successful Medical Billing and Reimbursement Practices
Texas Dept of Insurance - Division of Workers’ Compensation 2012 Presented by:
Regina Schwartz
This presentation is for educational
purposes only and
Provider Outreach maintains two
databases to record questions from
health care providers and other
system participants to identify
common billing and reimbursement
problems and to recommend
solutions.
Calls and Emails Received
85% from health care
providers/facilities or their staff
15% from other persons, including
insurance company
Payment reduced / denied
• Missed Deadlines
• Incorrect billing codes / modifiers • No preauthorization requested /
approved
• Services are not Medically necessary • Not compensable / not related to the
compensable injury
Patient
Intake Medical Service(s) Billing
Ask where, when and how the patient was injured
Ask for employer information Ask for insurance information
Is it covered by a workers’ compensation health care network?
If so, is the HCP a network provider?
Verify coverage
On TDI-DWC website, or call TDI- DWC coverage dept.
Identify a Workers’ Compensation Claim
and Verify Coverage
Provide Medically Necessary Treatments and Services
Refer to the ODG for
recommended treatments and services for the patient’s specific diagnosis/condition Know what services require preauthorization and that preauthorization was
requested and approved (in writing).
Processing a Workers’ Compensation Patient
What you need to know to bill
correctly
1. Info from intake
Is it a workers’ compensation claim? Who is the workers’ compensation insurance carrier?
Is it a workers’ compensation health care network claim?
If so, what network and is the HCP a network provider?
2. Info from medical
What procedures/treatments/services were provided?
Was preauthorization requested and obtained when required?
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 the employer
Tip #5 - Know and meet your deadlines
Tip #1
Identify a
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
Intake
What You Should Ask
• Did the injury happen on the job? When?
• Who was the employer?
• Did the employer have workers’
Intake
What You Should Ask
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• Who is the workers’ compensation insurance carrier?
• Is the medical coverage handled through a workers’ compensation health care network?
Workers’ Compensation Coverage
EMPLOYER Subscriber Covered Employers Workers’ Compensation Insurance Policy Certified Self-Insured and Group Self-Insured Public Employer Intergovernmental Risk Pools and Other Required Employers Non-Subscriber (Not Insured) Accident And Similar Policies No Coverage “Bare”How do I know if the patient’s
employer has workers’
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Call the DWC Insurance
Coverage Department
800-372-7713, opt. 6
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Who’s the insurance carrier?
Is it a network claim?
Certified Workers’ Compensation
Network
Certified under the Texas Insurance Code, Chapter 1305 DWC Medical Fee Guidelines (non-Network) Defined by Texas Labor Code, Section 413.011 Public Employer
Intergovernmental Risk Pools Section 504.053
Direct contract with health care
Tip #2
Understand the Use of the
Treatment Guidelines
and
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§408.021
Entitlement to Medical Benefits
The injured employee is entitled to all health care
reasonably required by the nature of the injury as and when needed that:
• Cures or relieves the effects naturally resulting from the compensable injury;
• Promotes recovery; or
• Enhances the ability of the
Medical services are presumed reasonably required
(medically necessary) when they are:
– Provided in accordance with prospective,
concurrent, or retrospective review processes. – Provided in accordance with the Division’s
Prospective and
Concurrent Review
Preauthorization and
Concurrent Review
Preauthorization is the prospective review of medical treatment and services for medical necessity
Concurrent review is the extension of
previously preauthorized treatments and services
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Preauthorization and
Concurrent Review
Treatments and services provided in a medical emergency do not require preauthorization or concurrent review
Approved treatment is not subject to
retrospective review of medical necessity. • Carrier can not deny payment for
Preauthorization and
Concurrent Review
Approved treatment is not a guarantee of payment
• Carrier can deny payment for
compensability, extent of injury,
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Voluntary Certification of Health Care
Prospective review of health care that does not require preauthorization or concurrent review
• The carrier may certify health care requested • The agreement must be documented
• Can not deny payment retrospectively for medical necessity or compensability
What medical services require
preauthorization and concurrent review?
• Types of non-emergency health care that requires preauthorization and concurrent review
Example
Non-emergency health care requiring preauthorization
(12) treatments and services that exceed or are not addressed by the commissioner’s
adopted treatment guidelines or protocols and are not contained in a treatment plan preauthorized by the insurance carrier. This requirement does not apply to drugs
prescribed for claims under §§134.506,
§413.011
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
Treatment Guidelines §137.100
Official Disability Guidelines – Treatment in Workers' Comp *
excluding the return to work pathways
(ODG)
*copy right © 2009 and published by Work Loss Data Institute
§137.100 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
The Official Disability Guidelines (ODG)
Provides a list of diagnoses and indicates the corresponding medical treatment for that diagnosis.
Treatment is:
• Recommended
ODG
and
ODG & Preauthorization
Requirements
Rule §134.600
Treatments and services that exceed or are not addressed by the Commissioner's adopted treatment guidelines or
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
ODG & Preauthorization Requirements
If the diagnosis and treatment • is in the ODG, and
• is recommended by the ODG Then preauthorization is required for
most treatments and services on the Division’s preauthorization list in
§134.600.
Carrier Liability
Section §413.014
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.
Tx recommended for your patient’s
specific condition? Tx on preauth list? Provide Treatment Subject to retrospective review of medical necessity Diagnosis in ODG? Request Preauthorization No Yes Yes No Yes No Request Preauthorization Request Preauthorization Tx exceed guidelines? Yes Request Preauthorization No
Tip #3
Labor Code
§413.011
Mandates that the Division establish medical policies and guidelines standard to other health care delivery systems, and
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Apply Medicare
• Reimbursement methodologies • Models, values or weights
• Coding, billing and reporting payment policies
• In effect on the date(s) of service • Unless DWC provides additions or
Medicare Policy Changes
By fee guideline rules, 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,
Medicare Biller Compensation Biller Workers’
A good resource for the
workers’ compensation
biller is the person who
bills for Medicare.
What would Medicare
CMS for National policies, and Non-DWC specific coding and billing issues: see the CMS website at
http://www.cms.hhs.gov/
Professional services (covers most
professional services): see the TrailBlazer Health website at
http://www.trailblazerhealth.com/
New Medicare Administrative
Contractor (MAC)
Novitas Solutions
www.novitas-solutions.com
The transition from TrailBlazer to Novitas Solutions is expected to be complete by late Nov. 2012
Durable medical equipment: see the Cigna Government Services website at
http://www.cignagovernmentservices.com
Dental, home health and some DME: see the Texas Medicaid and Healthcare Partnership website at
http://www.tmhp.com/default.aspx
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The Act & Rules prevail over CMS policies
Texas Labor Code or Division rules take
precedence over any conflicting provision used the CMS in administering the
Notwithstanding CMS policies, treatments or service should be covered if they are:
• Related to a compensable injury, • Medically necessary, and
• Medically reasonable
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Treatment Guidelines
Preauthorization & Concurrent Review
Tip #4
Understand and Manage the Benefits and Risks of Submitting the Bill for Medical
Rule 133.20 (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).
What are the benefits to the
health care provider for
Rule 133.20 (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
Rule 133.20 (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.
Rule 133.20 (j)
A health care provider is not allowed to submit a medical bill to an employer for charges an insurance carrier has reduced, denied or disputed.
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
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
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.
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.
Tip #5
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
Summary of Billing and
Health care providers submission a complete medical bill
Rule §133.20
Deadline: No later than 95 calendar days after the date of service
Exceptions to the 95 day rule
1) 95 days from the date the HCP was
notified that the bill was submitted to the wrong insurance carrier of HMO,
Health care providers submission a complete medical bill
Exceptions to the 95 day rule
2) 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, or
Carriers request for additional documentation
Rule 133.240
Deadline: Not later than the 45th calendar day after receipt of the medical bill
Health care providers response to a
carriers request for additional documentation Rule 133.20
Deadline: Not later than 15 calendar days after receipt of request for additional documentation
Carriers return of an incomplete medical bill
Rule 133.200
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 133.2 Clean Claim requirements are in Rule 133.10
Carriers payment of a complete medical bill
Rule 133.230
Deadline provide notice of decision to audit: Not later than 45 days after receipt of
medical bill;
Carriers final action (pay, reduce or deny) after review of a complete medical bill
Rule 133.240
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.
Health care providers request for reconsideration of a medical bill that was reduced or denied
Rule: 133.250
• Deadline: Not later than the 10th months from
date of service
– Health care provider cannot request
reconsideration until carrier has taken final action on bill or,
Carriers response to a request for
reconsideration of a medical bill that was reduced or denied
Rule 133.250
• Deadline if request is incomplete: Return within 7 calendar days of receiving request for reconsideration
• Deadline if request is complete: Reply within 30 calendar days of receiving request for reconsideration
Summary of Deadlines for Dispute
Resolution
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 217
There are three dispute paths
Dispute tracks can be identified from
information on the Explanation of Benefits
• EOB is required to contain sufficient
Why was the bill denied? What did the EOB say?
Compensability/ Extent of Injury/ Liability Not medically necessary Fees reduced or denied Reconsideration 10
months from the DOS Rule 133.250 Sublaimant dispute process DWC45 to FO
(no time limit for filing) Law 409.009
Rule 140.6
Reconsideration 10 months from the
DOS Rule 133.250
Reconsideration 10 months from the
DOS Rule 133.250
IRO dispute process LHL009 to IC 45 days
from reconsideration denial Rule 133.308
Medical Fee dispute process DWC60 to DWC central office 1 yr from the
DOS Rule 133.307
Preauth approved-bill denied for no
preauth Preauth approved-bill denied form lack of medical necessity Not a prerequisite
for filing for subclaimant status
Determining the Appropriate Disput Path when Your Fees are Denied or Reduced (Non-Network Claims)
Summary of Filing Deadlines for the
Preauthorization
Carrier to respond to a request for preauthorization
Rule 134.600
• 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
Health care provider to request
reconsideration for a preauthorization that was denied
Rule 134.600
Carrier to respond to a request reconsideration for a preauthorization that was denied
Rule 134.600
• As soon as practicable but not later than the 30th day after receiving a request for
reconsideration;
• within 3 working days of receipt of a request for reconsideration for concurrent review; or • within one working day of the receipt of the
request for reconsideration for inpatient length of stay.
Health care provider to request an independent review organization if reconsideration is
denied
Rule 133.308
• Deadline: Not later than 45th calendar
Carrier to notify the Health and Workers' Compensation Network Certification and Quality Assurance Division of the request for
an independent review organization
Rule 133.308
• Deadline: within 1 working day from the date the request is received
Independent review organization to provide a decision
Rule 133.308
• 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
(3) for retrospective medical necessity disputes, no later than the 30th day after the IRO receipt
Summary of Filing Deadlines in Texas
Workers’ Compensation for Reports:
Health care provider to file
DWC form 73, Work Status Report
Rule 129.5
• 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 2nd working day after the
Health care provider to file
DWC form 73, Work Status Report
Rule: 129.5
• Deadlines: Copies to carrier, employer, and
injured employee within 7 calendar days of the day of receipt of:
– an employer’s Bona Fide Offer of Employment
including a functional job descriptions and available modified duty positions, or
– a RME doctor's Work Status Report that indicates that the employee can return to work with or without
Health care provider to file
DWC form 69, Report of Medical Evaluation
Rule 130.1
• 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 130.1
Need
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Managed Care Quality Assurance Office (MCQA)
http://www.tdi.texas.gov/wc/wcnet/index.html
Workers' Compensation Health Care Networks (WCNet)
Independent Review Organizations (IRO) Utilization Review Agents (URA)
Telephone number: (512) 804-4812 Fax number: (512) 804-4811
Address:
7551 Metro Center Drive Suite 100 Austin, TX 78744 E-Mail: [email protected] WEB Page http://www.tdi.texas.gov/wc/mfdr/index.html
Inquiries on Active/Closed Medical Fee Disputes
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 Texas workers’ compensation system.
New Rules Process
1. Texas Legislature passes laws to provide guidance to TDI-DWC.
2. TDI-DWC staff drafts informal rules based on guidance in law.
New Rules Process
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
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.
New Rules Process
7. New and amended rules are adopted by the Commissioner of Workers’ Compensation.