THE QUESTION: I HAVE A PATIENT IN NEED OF SURGERY WITH WORKMAN’S COMP COVERAGE (WC). WILL I GET COMPENSATED FOR THIS? SHOULD I CONTINUE TO TAKE WC?
Will you be compensated? The short answer is yes. WC is not a network-based coverage plan. So long as they has a claim number from her WC carrier and they have accepted the claim you should be paid.💸💸💸
However there are caveats with WC coverage – such as reaching maximum medical improvement or the claim being controverted (e.g., not accepted by the payer because they’re making the argument that the employee wasn’t injured at work or were impaired/drunk/etc., thus they are not responsible for the injuries).
How does it work?
Essentially WC can work in two ways:
A – Take it from the ER and good luck (but be smart).
There’s more to it than that, but you would want to be sure the patient has the right information for you to ensure they are covered. If they JUST got injured at work and went to the ER, the chances of them having a Claim (e.g., in WC Claim = insurance case, not the traditional medical claim bill you send in to a carrier) on file is slim to none…they aren’t driving to the ER on the phone with their boss asking who the WC carrier is, finding that phone number, calling them, etc.
Now, if they were in the ER and they’re getting sent to you a few days later or even a day later, it surely is a possibility they may have started that process
What to ask for:
Employer Name, Address, Phone #, Manager or HR Director w/ contact info
WC Carrier, Claim Number, Adjustor (the person assigned to the case at the WC Carrier), contact info for the vendor AND the adjustor
Health Insurance Info – you want backup – check this out to be sure they have coverage in case the WC Claim is not accepted.
How to evaluate the case:
Guessing game. You nor I are in a position to decide if a WC carrier is going to accept a case. You can ask the patient what happened and make a logical assumption, but outside of general “this makes sense” we’re somewhat in the dark unless the patient has an approved case number. Even in this case, in some situations, the patient may have exhausted benefits for reasons such as Maximum Medical Improvement (MMI). An example of this would be a patient who injured a finger at work, underwent hand recon surgery and now has been in occupational therapy for X months. The WC Carrier may determine that no more OT or surgery is warranted because the patient has met MMI. This can be appealed etc. and is one of the WC sticking points, but a good example. Another example might be a scar from an injury at work that the patient wants laser or a revision on…same process there.
How to protect yourself:
Get that standard health insurance coverage as well. Just in case something is up with WC, you have a backup plan. Verify that it is active too! Now you don’t get to bill/get paid by both, and WC will always be primary to the health insurance with no patient liability (e.g., if WC pays that’s all you’re getting), but it also typically pays a bit better than commercial plans. Rates and regulations vary by state though.
Be sure you have the Claim Number and talk to the adjuster right away (or have your super Auctus RCM do so rather) to get a feel for where they are at (e.g. have they accepted the claim as payable).
If the patient has an attorney, get their info too. The attorneys can be helpful in pushing the case along if the carrier gives the patient and you any trouble. Now, I grew up with an attorney for a father so believe me when I say you will get different levels of optimism from different people. They often get paid on time and/or contingency so some attorneys will take cases with higher levels of risk.
B – You’re other way to going about it is getting a referral from an attorney.
If you go this route you generally have a relationship with the attorney and grow a level of trust for their judgment and can lean on them to evaluate the likelihood of coverage. All of the above suggestions/comments still apply in this case.
We also had one of our best Revenue Cycle Managers, @Kathleen Marasco, give her take on this question!
Kathleen – That was a beautiful response, @John Gwin. I will add a few comments. It does seem like your relevant state (Hawaii) is pretty Injured Worker/Provider friendly, but it’s always riskier if it’s a brand new claim. It is important as John noted to make sure your staff obtains all the relevant Workman’s Compensation information, which includes WC Insurance, Carrier name and claims address, Claim number, Date of Injury, Adjusters name and contact information (most have Phone, Fax and email). You should always attempt to get Prior Authorization for treatment from the
Adjustor where possible, especially if you are planning a surgery. In the event that the claim is contested/not approved, it would be important to have the patient’s private/commercial insurance on file and to have made sure you follow their guidelines as well to protect yourself.