Workers’ compensation cases historically represent 3 – 5% of hospital’s total A/R. And, they take up a disproportionate amount of resources to resolve when navigating through the complexities associated with on-the-job injury claims processing. That’s why it is a best practice to outsource workers’ compensation claims so internal staff can focus on the other 95% of cases that they are most qualified to adjudicate.
Why Workers' Compensation Claims are Complicated
There is limited data capture when patients come into the hospital because they typically do not have their employer's information readily available at the time of treatment.
From there, the account is handed off to the billing department without sufficient information, often resulting in delays in claim submission and tremendous use of staff resources to track down accurate information and associated needs to properly obtain payment. This leads to delayed reimbursement and wasted resources.
Further, if finally paid, hospitals will adjust balances that may be collectible when they don't know the amount of the precise expected payment as workers’ comp rates vary by state and can vary by hospital. In addition, if the claim is to be paid by a municipal, state or federal employee, there are different rules and requirements for these employers.
Some states have a fee schedule reimbursement, or rely on a Medicare or Medicaid based model, while others have a usual and customary (U&C) process. As well, providers can choose to contract with managed care payers or find silent PPs involved. There are many different models, and they are difficult to keep current and ensure that the provider is properly reimbursed.
Additionally, underpayment appeal periods may vary. Some states do not have statutory time limits, while others may only provide 15 days to appeal or up to 3 years for disputed charges.
What to Evaluate When Outsourcing Workers' Comp
To ensure proper payment, it is important to outsource workers' compensation claims to specialized vendors who have:
-Paperless workflow management
-Resources to facilitate and document correspondence between payer organizations, providers and patients
Implementation and Beyond
During onboarding, both parties should have a clear understanding of the provider’s needs, including:
- Connectivity, remote access and IT integrations
- File transfer and workflow automation for maximum efficiency
- KPIs and reporting
Ultimately, outsourcing workers' compensation to a trusted partner will allow you to work toward the highest net return while also receiving the highest levels of administrative effectiveness and patient satisfaction.
To learn more about how Parallon works workers' compensation claims, reach out to our experts.