Tips for Sucessful Billing and Reimbursement Practices for Workers
Transcription
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 99 Any Questions?