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How to Appeal a Workers’ Comp Medical Billing Claim

In medical billing, appealing a workers’ comp claim can sometimes be tricky. Often an out-of-network payer is responsible for paying a Workers’ Compensation claim. Many states have legislation in place or fee schedules that outline how Workers’ Compensation claims will be paid.

Other carriers participate in networks that offer pricing for these claims. Some organizations, referred to as silent PPOs, price claims for carriers who don’t have a contract with the service provider as though the provider participates in the network. The provider has the right to fight these discounts.

Workers’ Compensation claims demand up-front work. Someone in the provider’s office should be responsible for verifying benefits, and this person should also verify the Workers’ Compensation eligibility of the patient prior to any procedure being performed. (Coders are very good at verifying benefits because they have a thorough understanding of planned procedures and supporting diagnosis codes.)

Each Workers’ Compensation patient has a caseworker, who is usually the coordinator for medical care, and this caseworker’s name appears on any paperwork you receive. When dealing with Workers’ Comp, you also work with an adjuster, who is responsible for coordinating the provider claims.

Most Workers’ Compensation claims have a set amount that has been approved to pay for medical expenses related to the worker’s injury. The adjuster keeps track of these funds and may need to go back to the carrier and ask for additional funds. Get the adjuster’s name up front and give him a call to make sure you know where to send the claim and what additional documentation you need.

In addition to communicating with the caseworker and adjuster, you also want to verify the claim number, date of injury, and the body part that relates to the claim. Many carriers also require that all claims be submitted with the approved diagnosis code, so make sure that you and your employer know what diagnosis is covered.

When the claim is paid other than expected, referencing a network with which the provider is not familiar and taking a discount that the provider has not agreed to, then the appeals process begins. Often these underpriced claims are sent to the provider’s attorney for a settlement. Depending on the office structure, the office manager or administrator is the one who sends the claim to the company attorney for action.

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