In workers' compensation, it's important to create a "clean bill" for presentment to the proper payer as quickly as possible. Processing tactics are focused on healthcare claims adjudication, not collections. The goal is to provide maximum reimbursement and ease of doing business.
Here is the process revenue cycle vendors should follow to ensure timely turnarounds for account resolution:
The account is received electronically via file exchange.
Investigate and Confirm
Investigation should be performed by specialized representatives who work with payers who have intimate knowledge of what a payer (and employer) requires and expects to promptly and adequately have claims process for payment.
Medical records should be obtained electronically, attached to the claim, with both submitted electronically to the paying entity at the time of billing.
Gather Documents and Bill
If required, the representative should contact the employer or potentially the patient for additional information through tailored letters and/or telephone calls.
Follow-up and Re-bill
Intimate knowledge of payers should drive tailored encounter management for follow-up timing with emphasis on driving prompt and accurate payment.
Confirm and Post
Upon receipt of payment, there should be an urgent review process for accuracy, regardless of balance size or age of encounter. They should be reviewed by a payment specialist familiar with workers’ compensation in order to ensure correct payment was received.
Denials and underpayments should be quickly identified and appealed promptly. There are silent PPOs and other workers’ comp discounts in managed care contracts that providers may not be aware of and could affect reimbursement.
As a true partnership, your workers' compensation vendor should provide continuous feedback to improve front-end functions for maximum efficiency in claims production and turnaround time.
Choose a revenue cycle vendor that reports out monthly on placements and activity, providing a high-level analysis of results to determine where there may be gaps.
Because workers' compensation claims are traditionally a paper-laden process, look for a vendor that has the technology to handle submissions with necessary attachments electronically, including itemized bills, medical records, purchase orders and EOBs, which are all critical to track for proper reimbursement.
Also, ensure they have expert knowledge in coordination of benefits, workers’ compensation laws and regulations and reimbursement models for their state or region.
Lastly, they should employ specific specialists and clinical team members to represent your accounts that perform successful appeals, arbitration and audit reviews.
Want to learn more about how are workers' compensation services can drastically reduce your write-offs? Contact one of our revenue cycle experts.