Workers’ Compensation Medical Billing & Credentialing Guide

Yes, we understand your hands are full of patients needing care services. You are occupied with charting their symptoms, diagnosing the illness, selecting the appropriate treatment plan, documenting, processing claims, and posting payments. In all this, navigating workers’ compensation billing and credentialing can exhaust you!

Thus, we have prepared this guide to act as a roadmap for cracking the workers’ compensation (aka workers’ comp) billing, streamlining the workflow, and understanding the common challenges that may impact your practice’s financial health. 

Workers’ Compensation in Medical Billing

It is a state government-mandated program, but the benefits and guidelines may vary from one state to another. Workers’ compensation in medical billing is an insurance coverage that benefits employees if they fall sick or get injured at work. It may cover various diseases and injuries, including hazardous chemical exposure, needlestick wounds, or back disorders.

It also covers rehabilitation fees, lost earnings, medical expenditures, and compensation for long-term disability. Healthcare providers use CPT codes to bill for services rendered to patients insured under this plan.

Common Challenges of Workers’ Compensation Billing

Before diving into the workers’ comp billing guidelines, let’s first discuss the common challenges associated with it:

• You may not receive a response when following up on a claim submitted to the workers’ comp insurance carrier.
• The insurance carrier may ask for additional documentation that is unavailable.
• There is no online portal for tracking workers’ comp claim status.
• There is a lack of proper benefit-checking processes.
• Receiving claim denials without an explanation from the insurance carrier.
• Another challenge is receiving underpayment or lower reimbursements.

Workers’ Compensation Credentialing

Workers’ compensation credentialing means that a healthcare provider or facility signs a contract with a workers’ comp carrier/payer to boost the practice’s patient referrals.

Simply put, providers must be contracted with a specific panel, network, or carrier depending upon state regulations to receive referrals from workers’ comp payers.

Besides, the contracting ensures that the fee schedule is agreed upon and fosters understanding between the insurance carrier and physician.

Workers’ Compensation Billing and Credentialing Guidelines

Medical billing is complex, and when it comes to workers’ comp, things become more vague if you don’t have an in-house team of certified professional coders (CPCs) or billing specialists. Thus, here are some billing and credentialing guidelines to help you overcome your reimbursement struggles!

Workers’ Compensation Credentialing Guidelines

Not sure, how to streamline the workers’ comp contracting? Don’t worry, this section will help you out!

Contract with Employers and Payers

You will receive patient referrals from employers and payers only if you are contracted by them. Thus, to increase your practice’s profitability, you should start by credentialing with workers’ compensation-designated panels or networks.

Ensure Accurate Listing

Another workers’ compensation credentialing best practice is to ensure accurate listing. Even if you are already listed on the designated networks or panels, we recommend you double-check your listing. 

Besides, physician lists have several search terms and tags that you can use to increase your chances of appearing in search results. Also, keep your address, contact details, and email address updated.

Renegotiate for Higher Rates

Are you dissatisfied with your current reimbursement rates for the rendered services or procedures? Some states allow you to renegotiate. Thus, you should use your right and ask for higher reimbursement rates from the designated network or carrier. 

Contract with IME Panels

Don’t just settle for network contracts! Also, focus on credentialing with independent medical evaluation (IME) panels. Various IME panels have different rates, but you can decide your reimbursement rates. However, setting a high rate may minimize your IME patient referrals.

Workers’ Compensation Billing Guidelines

Here are some best practices to help you optimize your workers’ compensation billing and collection process:

Use Medical Billing Workers’ Compensation Software

Start using a medical billing software to automate the process, including eligibility verification, claim submission, and requesting medical records. It will also help you track claim denials and collections.

Besides, electronically submitting claims will help you adhere to the filing deadlines. Moreover, alerts and checks will help you identify and rectify coding errors promptly, increasing the claim first-pass rate.

Verify Eligibility and Verification

We recommend you verify the patient’s workers’ comp eligibility and benefits before rendering services to avoid payment delays and denials.

Hire a Billing Specialist

A workers’ compensation billing specialist can help you with eligibility verification, claim submission, A/R status follow-up, and denial management. If you don’t want to hire, you can outsource medical billing services to streamline your workers’ comp workflow.

Train Your Staff on the Workers’ Comp Jargon

Workers’ comp involves specialized terminologies, such as utilization review, which your staff must learn for seamless claim processing and collection workflow.

Optimize the Documentation Process

A lot of paperwork is involved in workers’ comp. Thus, strive to create a system to streamline the documentation process. You must ensure that complete and accurate information is entered during claim submission to support medical necessity and appropriateness of the rendered procedure or service.

Effectively Manage Denials

Receiving claim denials is a common issue. Thus, it is advisable to focus on implementing rigorous denial management strategies to reduce the likelihood of denials and resolve them if they occur.

Follow Up on Claim Status

Another workers’ compensation billing guideline is to monitor and track claims status to ensure timely reimbursements, as payment delays can negatively impact your practice’s revenue cycle.

How to Appeal Workers’ Compensation Related Denials?

There can be different reasons for a workers’ comp claim denial. The most common causes for denial are as follows:

• Rendered service or procedure is not covered under the policy.
• The claim may lack medical necessity.
• You did not follow medical billing and coding guidelines related to workers’ comp.
• You did not obtain pre-authorization before providing services.
• The patient failed to meet his/her maximum medical improvement.

Regardless of the reason, the good news is you can appeal the denial. However, it can be complicated to understand the process. So, we have simplified it for you. 

Here’s how it typically goes:

• The healthcare provider appeals the insurance payer’s decision with additional supporting documentation if required.
• If the payer denies the appeal, the physician has the right to file a notice of contest with the workers’ comp board.
• The workers’ comp board reviews the case and all the documentation to reach a verdict.
• If the decision is in favor of the provider, the payer is liable to reimburse for the provided care services.

List of Most Common Workers’ Compensation Billing CPT Codes

Some of the common CPT codes for workers’ comp billing are listed below:

Workers’ Comp CPT Codes	Description
99203	Outpatient or office visits with a new patient, involving low-level medical decision-making.
99455	Review of medical or work-related disability.
97110	Therapeutic workouts with activities and exercises designed to improve a patient’s fitness and mobility.
90791	Psychiatric assessment of patient’s mental health.
99214	Outpatient or office visits with an established patient, involving moderate medical decision-making.
99215	Outpatient or office visits with an established patient, involving significant medical decision-making.
97750	Examinations of the patient’s physical performance, such as the ability to do daily activities and joint health.

Bottom Line

Workers’ compensation billing and credentialing is when healthcare providers partner with government and private insurance companies to offer care services to injured or ill employees in return for rightful reimbursements. 

By implementing best practices like automation, eligibility verification, outsourcing, and effective denial management, you can stay on top of billing and credentialing challenges, leading to increased patient referrals and higher reimbursements. 

The list of CPT codes used in workers’ comp will give you a general idea of what is covered under this program if you are not already a signatory of an agreement with a workers’ comp insurance carrier or network.