Tips for Sucessful Billing and Reimbursement Practices for Workers

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
This presentation is for educational
purposes only and
is not a substitute for the
Law and Division Rules
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
Calls and Emails Received
85% from health care
providers/facilities or their staff
15% from other persons, including
insurance company
representatives, attorneys, etc.
4
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
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
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
Tip #1
Identify a
Workers’ Compensation Patient
8
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
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
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
Workers’ Compensation Coverage
EMPLOYER
NonSubscriber
(Not Insured)
Subscriber
Covered
Employers
Workers’
Compensation
Insurance
Policy
Certified
Self-Insured
and Group
Self-Insured
Public
Employer
Intergovernmental
Risk Pools
and
Other
Required
Employers
Accident
And
Similar
Policies
No
Coverage
“Bare”
§406.002 – 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
12
How do I know if the patient’s
employer has workers’
compensation coverage?
14
http://www.tdi.texas.gov/wc/employer/coverage.html
15
Call the DWC Insurance
Coverage Department
800-372-7713, opt. 6
In Austin: 804-4000, opt. 6
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
DWC Medical Fee
Guidelines
(non-Network)
Certified under the
Texas Insurance
Code,
Chapter 1305
Defined by Texas
Labor Code,
Section 413.011
Public Employer
Intergovernmental Risk Pools
Section 504.053
17
Direct contract
with health care
providers
Tip #2
Understand the Use of the
Treatment Guidelines
and
When to Request Preauthorization
§408.021
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
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
Prospective and
Concurrent Review
Does not apply to network Claims
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
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
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
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
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
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 §§134.506,
134.530 or 134.540 of this title (relating to
Pharmaceutical Benefits);
27
Treatment
Guidelines
28
§413.011
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
Treatment Guidelines
§137.100
Official Disability Guidelines –
Treatment in Workers' Comp *
excluding the return to work pathways
(ODG)
*copy right © 2009 and published by Work Loss Data Institute
http://www.worklossdata.com/PR_Texas.htm
30
§137.100 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
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
ODG
and
Preauthorization
ODG & Preauthorization
Requirements
Rule §134.600
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
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
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
§134.600.
36
Carrier Liability
Section §413.014
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
Typical Treatment / Preauthorization Decisions
Diagnosis
in
ODG?
No
Request
Preauthorization
Yes
Tx
recommended
for your patient’s
specific
condition?
Yes
Tx
exceed
guidelines?
No
Tx on
preauth
list?
No
Yes
Yes
Request
Preauthorization
Request
Preauthorization
Request
Preauthorization
38
No
Provide
Treatment
Subject to
retrospective
review of
medical
necessity
Tip #3
Stay Current with Changes
from Centers for Medicare
and Medicaid Services (CMS)
Labor Code
§413.011
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
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
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
A good resource for the
workers’ compensation
biller is the person who
bills for Medicare.
Medicare Biller
What
would
Medicare
do?
Workers’
Compensation Biller
External Resources (CMS and MACs)
CMS for National policies, and Non-DWC
specific coding and billing issues: see the
CMS website at
http://www.cms.hhs.gov/
Professional services (covers most
professional services): see the TrailBlazer
Health website at
http://www.trailblazerhealth.com/
New Medicare Administrative
Contractor (MAC)
Novitas Solutions
www.novitas-solutions.com
The transition from TrailBlazer to Novitas
Solutions is expected to be complete by
late Nov. 2012
45
External Resources (CMS and MACs)
Durable medical equipment: see the Cigna
Government Services website at
http://www.cignagovernmentservices.com
Dental, home health and some DME: see the
Texas Medicaid and Healthcare Partnership
website at
http://www.tmhp.com/default.aspx
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
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
Texas workers’ compensation payment
policy rules work in conjunction with
other Division rules
Treatment Guidelines
Preauthorization & Concurrent
Review
49
Tip #4
Understand and Manage the Benefits and
Risks of Submitting the Bill for Medical
Services to the Employer
Rule 133.20 (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
What are the benefits to the
health care provider for
billing the employer?
Rule 133.20 (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
Rule 133.20 (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
Rule 133.20 (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
What are the risks associated with
billing the employer?
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
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
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
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
Tip #5
Know and Meet Your
Deadlines
What happens if I miss filing
deadlines?
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
Summary of Billing and
Reimbursement Deadlines
Health care providers submission a
complete medical bill
Rule §133.20
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
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
Carriers request for additional
documentation
Rule 133.240
Deadline: Not later than the 45th calendar
day after receipt of the medical bill
67
Health care providers response to a
carriers request for additional documentation
Rule 133.20
Deadline: Not later than 15 calendar days
after receipt of request for additional
documentation
Medical documentation rule: 133.210
68
Carriers return of an incomplete
medical bill
Rule 133.200
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 133.2
Clean Claim requirements are in Rule 133.10
69
Carriers payment of a complete
medical bill
Rule 133.230
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
Carriers final action (pay, reduce or deny)
after review of a complete medical bill
Rule 133.240
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
Health care providers request for reconsideration of
a medical bill that was reduced or denied
Rule: 133.250
• Deadline: Not later than the 10th 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
Carriers response to a request for
reconsideration of a medical bill that was
reduced or denied
Rule 133.250
• 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
Summary of Deadlines for Dispute
Resolution
(Non-Network)
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 217
75
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
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?
Not a prerequisite
for filing for
subclaimant status
Preauth approvedbill denied for no
preauth
Preauth approvedbill denied form lack
of medical necessity
Compensability/
Extent of Injury/
Liability
Not medically
necessary
Fees reduced
or denied
Reconsideration 10
months from the
DOS
Rule 133.250
Reconsideration 10
months from the
DOS
Rule 133.250
Reconsideration 10
months from the
DOS
Rule 133.250
Sublaimant dispute
process DWC45 to FO
(no time limit for filing)
Law 409.009
Rule 140.6
IRO dispute process
LHL009 to IC 45 days
from reconsideration
denial Rule 133.308
Medical Fee dispute
process DWC60 to DWC
central office 1 yr from the
DOS Rule 133.307
77
Summary of Filing Deadlines for the
Preauthorization
Process
Carrier to respond to a request for
preauthorization
Rule 134.600
• 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
Health care provider to request
reconsideration for a preauthorization
that was denied
Rule 134.600
• Deadline: 30 working days of denial
80
Carrier to respond to a request reconsideration
for a preauthorization that was denied
Rule 134.600
• 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
Health care provider to request an independent
review organization if reconsideration is
denied
Rule 133.308
• Deadline: Not later than 45th calendar
day after receipt of denial of request for
reconsideration
82
Carrier to notify the Health and Workers'
Compensation Network Certification and
Quality Assurance Division of the request for
an independent review organization
Rule 133.308
• Deadline: within 1 working day from
the date the request is received
83
Independent review organization to
provide a decision
Rule 133.308
• 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
84
of the IRO fee
Summary of Filing Deadlines in Texas
Workers’ Compensation for Reports:
DWC form 73 and
DWC form 69
Health care provider to file
DWC form 73, Work Status Report
Rule 129.5
• 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 2nd working day after the
date of examination
86
Health care provider to file
DWC form 73, Work Status Report
Rule: 129.5
• 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
87
restrictions.
Health care provider to file
DWC form 69, Report of Medical Evaluation
Rule 130.1
• 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 130.1
88
Need
Assistance?
General Information about
Medical Services
Submit question to
[email protected]
Subscribe to eNews
http://www.tdi.texas.gov/alert/emailnews.html
91
Managed Care Quality Assurance Office (MCQA)
http://www.tdi.texas.gov/wc/wcnet/index.html
Workers' Compensation Health Care Networks
(WCNet)
[email protected]
Independent Review Organizations (IRO)
Utilization Review Agents (URA)
[email protected]
92 92
Inquiries on Active/Closed Medical Fee Disputes
Telephone number: (512) 804-4812
Fax number: (512) 804-4811
Address:
7551 Metro Center Drive
Suite 100
Austin, TX 78744
E-Mail:
[email protected]
WEB Page
http://www.tdi.texas.gov/wc/mfdr/index.html
93
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.
http://www.tdi.texas.gov/wc/rules/index.html
94
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
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 TDIDWC staff. The comments are used in
preparing the rules for formal proposal for
public comment.
96
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 TDIDWC staff. The comments are used in
preparing the rules for adoption.
97
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
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Any
Questions?