Workers' Compensation Billing for Physical Therapy

Billing is very tricky, we understand. Even more when we add workers’ compensation claims to the mix. While the treatment itself may be straightforward, the intricacies of workers' compensation billing can be confusing, especially with variations across different states. This blog post outlines five key steps to navigate workers' compensation authorization and billing, along with valuable resources for physical therapy practices.

Understanding Workers' Compensation Billing

According to the American Association of Professional Coders, “Workers’ compensation provides coverage for wage replacement benefits, medical treatment, vocational rehabilitation, and other benefits to workers who are injured at work or acquire an occupational disease.”

Now, let’s talk billing; for successful reimbursement, adhering to specific billing guidelines is crucial. These guidelines ensure timely payments and minimize errors. The process, while distinct from typical insurance billing, shares some similarities. Instead of verifying insurance benefits, therapists need to confirm the injury's work-related nature and utilize the appropriate claim forms.

Key Steps for Workers' Compensation Billing:

1. Confirming Work-Related Injury: This initial step prevents potential issues. If a patient fails to mention a work-related injury, the provider might inadvertently bill their primary insurance, leading to unnecessary complications and potential claim denials. So the first step it’s to know if the patient’s injury falls under Workers’ Comp.
2. Verifying Claim Details: Now, once the work-related nature is confirmed, therapists need to verify specific details on the claim, such as the adjuster's name, patient information, claim number, and injury details. Additionally, many carriers require the approved diagnosis to be listed on the claim. 
3. Obtaining Treatment Authorization: Before starting treatment, contacting the listed adjuster is essential. Importantly, obtaining written authorization safeguards the practice in case of claim denials since it might not be easy to do so with only verbal authorization. 
4. Tracking Visits and Maintaining Documentation: Meticulously tracking authorized visits and maintaining detailed documentation is crucial. Claims might be denied if service dates or visit counts deviate from the approved authorization. Therapists should proactively contact the adjuster if additional treatment is needed to avoid service denials for future visits. Additionally, some payers require specific patient documentation with the claim, which should be attached accordingly.

It's important to remember that workers' compensation insurance typically doesn't involve deductibles or copayments for patients. Providers must accept the reimbursement from the payer as full payment, and balance billing is strictly prohibited.

5. Follow the rules: 

• Do not bill the employer due to HIPAA privacy rules.
• Be familiar with federal and state workers' compensation regulations.
• Use the correct forms:
• First Report of Injury Form (completed by the provider at the first visit)
• CMS-1500 Claim Form (submitted by the biller with documentation)
• Accept workers' compensation payment as full payment according to your state's fee schedule. 

Additional Resources:

Beyond the five key steps, numerous resources can support a smooth workers' compensation billing process for physical therapists:

State Regulations: The American Physical Therapy Association (APTA) provides a resource listing each state's workers' compensation authority website and relevant PT claim requirements. This can be particularly helpful when encountering roadblocks during the claim process.

Workers' Compensation Medical Fee Schedules: This resource delves into the reasons why states with fee schedules established their current rates. This can serve as a valuable guide for PT professionals to understand their state's specific fee schedules and ensure fair reimbursements.

Mastering workers' compensation billing can feel like navigating a maze, but don't worry!

Advanced Rehab Management Services is an expert when it comes to Workers’ Compensation processing. In fact, our third-party administrator license allows us to collect the maximum reimbursement from insurance companies on your behalf. If you’re not receiving 100% of your state’s fee schedule, then contact us right away! We can help. [email protected] | www.ar-mgt.com/contact