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What You Need to Know about Billing Workers’ Comp for Medical Expenses

As a medical billing professional, it’s important to understand that each state has its own guidelines for Workers’ Compensation claim payments. In states that have Workers’ Compensation fee schedules, these fee schedules function the same as a provider contract; the claim processes according to the fee schedule. If the provider treats a Workers’ Comp patient, the payment guidelines that apply are those where the patient’s employer filed the claim.

Check out this example. Patient Bob works for a company that is headquartered in Kentucky. Bob lives in Illinois (which has a Workers’ Compensation state fee schedule) but has surgery in Missouri (which has no Workers’ Compensation fee schedule). The Kentucky employer files the claim with its carrier in Kentucky, and the Missouri provider is obligated by the payment guidelines of Kentucky.

Therefore, if you’re coding the payment for a Workers’ Compensation claim settlement, educate yourself and possibly your employer about the Workers’ Comp laws of the state where the claim was filed. Most states have this information on their websites. You can also obtain the necessary information by calling the State Department of Injured Workers.

If the state-legislated payment rules are violated and a commercial payer sends incorrect payment, then the provider has grounds to file an appeal, and it’s your job as the coder to appeal, and appeal again until your provider has been paid correctly. If no contract or pre-payment agreement exists, then the provider is under no obligation to accept the payment as full claim settlement. Bottom line: Know before you file.

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