Texas Workers Compensation

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1 Texas Workers Compensation Tips for Successful Medical Billing and Reimbursement Practices Presented by: Regina Schwartz Health Care Specialist Texas Dept of Insurance - Division of Workers Compensation 2012

2 This presentation is for educational purposes only and is not a substitute for the Law and Division Rules

3 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. 3

4 Calls and s Received 85% from health care providers/facilities or their staff 15% from other persons, including insurance company representatives, attorneys, etc. 4

5 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 Payment made per fee guidelines 5

6 Processing a Workers Compensation Patient Patient Intake Medical Service(s) Billing Identify a Workers Compensation Claim and Verify Coverage Provide Medically Necessary Treatments and Services What you need to know to bill correctly 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. 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). 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? Get medical documentation to send with the bill, when required 3. Know the Fee Guideline and Medicare billing and reimbursement policies. 6

7 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 7

8 Tip #1 Identify a Workers Compensation Patient 8

9 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 9

10 Intake What You Should Ask Did the injury happen on the job? When? Who was the employer? Did the employer have workers compensation coverage on the date of injury? 10

11 Intake What You Should Ask Who is the workers compensation insurance carrier? Is the medical coverage handled through a workers compensation health care network? If so, does the health care provider have a contract with the network? 11

12 Workers Compensation Coverage EMPLOYER Subscriber Non- Subscriber (Not Insured) Covered Employers Workers Compensation Insurance Policy Certified Self-Insured and Group Self-Insured Public Employer Intergovernmental Risk Pools and Other Required Employers 12 Accident And Similar Policies No Coverage Bare Except for public employers and as otherwise provided by law, only employers who elect to obtain workers compensation coverage are subject to the Labor Code

13 How do I know if the patient s employer has workers compensation coverage?

14 14

15 15

16 Call the DWC Insurance Coverage Department , opt. 6 In Austin: , opt. 6

17 Who s the insurance carrier? Is it a network claim? Does the health care provider have a contract with the network? Certified Workers Compensation Network Certified under the Texas Insurance Code, Chapter 1305 DWC Medical Fee Guidelines (non-network) Defined by Texas Labor Code, Section Public Employer Intergovernmental Risk Pools Section Direct contract with health care providers 17

18 Tip #2 Understand the Use of the Treatment Guidelines and When to Request Preauthorization

19 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 employee to return to or retain employment. 19

20 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 adopted treatment guidelines, and 20

21 Prospective and Concurrent Review Does not apply to network Claims

22 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 22

23 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 medical necessity reasons 23

24 Preauthorization and Concurrent Review Approved treatment is not a guarantee of payment Carrier can deny payment for compensability, extent of injury, relatedness to the injury, or liability issues 24

25 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 Denial of a request is not subject to dispute resolution 25

26 What medical services require preauthorization and concurrent review? Types of non-emergency health care that requires preauthorization and concurrent review Not a list of CPT codes 26

27 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 , or of this title (relating to Pharmaceutical Benefits); 27

28 Treatment Guidelines 28

29 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 29

30 Treatment Guidelines Official Disability Guidelines Treatment in Workers' Comp * excluding the return to work pathways (ODG) *copy right 2009 and published by Work Loss Data Institute 30

31 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 31

32 The Official Disability Guidelines (ODG) Provides a list of diagnoses and indicates the corresponding medical treatment for that diagnosis. Treatment is: Recommended Not recommended Under study 32

33 ODG and Preauthorization

34 Rule ODG & Preauthorization Requirements 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 carrier. 34

35 ODG & Preauthorization Requirements 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 35

36 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

37 Section Carrier Liability 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. 37

38 Typical Treatment / Preauthorization Decisions Diagnosis in ODG? Yes Tx recommended for your patient s specific condition? Yes Tx exceed guidelines? No Tx on preauth list? No Provide Treatment Subject to retrospective review of medical necessity No No Yes Yes Request Preauthorization Request Preauthorization Request Preauthorization Request Preauthorization 38

39 Tip #3 Stay Current with Changes from Centers for Medicare and Medicaid Services (CMS)

40 Labor Code Mandates that the Division establish medical policies and guidelines standard to other health care delivery systems, and Mandates the use of most current CMS weights, values, measures and payment policies. 40

41 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 exceptions in billing and reimbursement policies 41

42 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, whichever is later

43 A good resource for the workers compensation biller is the person who bills for Medicare. What would Medicare do? Medicare Biller Workers Compensation Biller

44 External Resources (CMS and MACs) CMS for National policies, and Non-DWC specific coding and billing issues: see the CMS website at Professional services (covers most professional services): see the TrailBlazer Health website at

45 New Medicare Administrative Contractor (MAC) Novitas Solutions The transition from TrailBlazer to Novitas Solutions is expected to be complete by late Nov

46 External Resources (CMS and MACs) Durable medical equipment: see the Cigna Government Services website at Dental, home health and some DME: see the Texas Medicaid and Healthcare Partnership website at

47 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 Medicare program. 47

48 Notwithstanding CMS policies, treatments or service should be covered if they are: Related to a compensable injury, Medically necessary, and Medically reasonable Applies to network and non-network claims 48

49 Texas workers compensation payment policy rules work in conjunction with other Division rules Treatment Guidelines Preauthorization & Concurrent Review 49

50 Tip #4 Understand and Manage the Benefits and Risks of Submitting the Bill for Medical Services to the Employer

51 Rule (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). 51

52 What are the benefits to the health care provider for billing the employer?

53 Rule (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 53

54 Rule (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. 54

55 Rule (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. 55

56 What are the risks associated with billing the employer?

57 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 care provider. 57

58 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 health care provider forfeiting the right to payment from the insurance carrier. 58

59 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. 59

60 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. After this time limit, send a bill to the insurance carrier requesting payment. 60

61 Tip #5 Know and Meet Your Deadlines

62 What happens if I miss filing deadlines?

63 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 63

64 Summary of Billing and Reimbursement Deadlines

65 Health care providers submission a complete medical bill Rule 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, 65

66 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 3) By agreement of the parties 66

67 Carriers request for additional documentation Rule Deadline: Not later than the 45th calendar day after receipt of the medical bill 67

68 Health care providers response to a carriers request for additional documentation Rule Deadline: Not later than 15 calendar days after receipt of request for additional documentation Medical documentation rule:

69 Carriers return of an incomplete medical bill Rule 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 Clean Claim requirements are in Rule

70 Carriers payment of a complete medical bill Rule Deadline provide notice of decision to audit: Not later than 45 days after receipt of medical bill; Deadline to complete the audit: Within 160 days after receipt of complete medical bill. 70

71 Carriers final action (pay, reduce or deny) after review of a complete medical bill Rule 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. 71

72 Health care providers request for reconsideration of a medical bill that was reduced or denied Rule: Deadline: Not later than the 10 th months from date of service Health care provider cannot request reconsideration until carrier has taken final action on bill or, Health care provider has not received an explanation of benefits within 50 days from submitting the medical bill. 72

73 Carriers response to a request for reconsideration of a medical bill that was reduced or denied Rule 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 73

74 Summary of Deadlines for Dispute Resolution (Non-Network)

75 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

76 There are three dispute paths Dispute tracks can be identified from information on the Explanation of Benefits EOB is required to contain sufficient detail to explain factual basis of action (Rule 133.3) 76

77 Determining the Appropriate Disput Path when Your Fees are Denied or Reduced (Non-Network Claims) Why was the bill denied? What did the EOB say? Preauth approvedbill denied for no preauth Not a prerequisite for filing for subclaimant status Compensability/ Extent of Injury/ Liability Not medically necessary Fees reduced or denied Preauth approvedbill denied form lack of medical necessity Reconsideration 10 months from the DOS Rule Reconsideration 10 months from the DOS Rule Reconsideration 10 months from the DOS Rule Sublaimant dispute process DWC45 to FO (no time limit for filing) Law Rule IRO dispute process LHL009 to IC 45 days from reconsideration denial Rule Medical Fee dispute process DWC60 to DWC central office 1 yr from the DOS Rule

78 Summary of Filing Deadlines for the Preauthorization Process

79 Carrier to respond to a request for preauthorization Rule 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 79

80 Health care provider to request reconsideration for a preauthorization that was denied Rule Deadline: 30 working days of denial 80

81 Carrier to respond to a request reconsideration for a preauthorization that was denied Rule 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. 81

82 Health care provider to request an independent review organization if reconsideration is denied Rule Deadline: Not later than 45 th calendar day after receipt of denial of request for reconsideration 82

83 Carrier to notify the Health and Workers' Compensation Network Certification and Quality Assurance Division of the request for an independent review organization Rule Deadline: within 1 working day from the date the request is received 83

84 Independent review organization to provide a decision Rule 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 of the IRO fee 84

85 Summary of Filing Deadlines in Texas Workers Compensation for Reports: DWC form 73 and DWC form 69

86 Health care provider to file DWC form 73, Work Status Report Rule 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 2 nd working day after the date of examination 86

87 Health care provider to file DWC form 73, Work Status Report Rule: 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 restrictions. 87

88 Health care provider to file DWC form 69, Report of Medical Evaluation Rule 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

89 Need Assistance?

90

91 General Information about Medical Services Submit question to Subscribe to enews 91

92 Managed Care Quality Assurance Office (MCQA) Workers' Compensation Health Care Networks (WCNet) Independent Review Organizations (IRO) Utilization Review Agents (URA) 92 92

93 Inquiries on Active/Closed Medical Fee Disputes Telephone number: (512) Fax number: (512) Address: 7551 Metro Center Drive Suite 100 Austin, TX WEB Page 93

94 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. 94

95 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. 95

96 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 preparing the rules for formal proposal for public comment. 96

97 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. 97

98 New Rules Process 7. New and amended rules are adopted by the Commissioner of Workers Compensation. 8. New and amended rules are implemented in the Texas workers compensation system. 98

99 99

100 Any Questions?

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