Maximizing Your Workers’ Compensation Claims
By Josie Sackmann, Executive Vice President of Workers’ Compensation, Elevate Patient Financial Solutions®
Even though workers’ compensation claims may make up a small part of a healthcare provider’s A/R inventory, knowing how to best handle these claims can maximize a valuable revenue source that often doesn’t receive enough attention. Having the right revenue cycle management partner by your side can make all the difference in improving cash flow, decreasing aging, and bringing to light why payers underpay.
Here’s what to consider to increase your workers’ compensation collections:
Specialized Knowledge in Every State
Having an RCM partner with a national presence and footprint ensures the expertise necessary to effectively collect on claims from any state of jurisdiction. Vast differences in the administrative rules, filing deadlines, and processing timelines exist from state to state. Most importantly, fee schedules are not universal, and having the unique expertise of what is payable in each state is key to maximizing reimbursement on each and every claim.
If a healthcare provider manages their workers’ compensation claims internally, chances are their team doesn’t possess the knowledge or have the time needed to do it properly to maximize cash. Additionally, in the event the claim will not be covered by a workers’ compensation carrier, it is critical to understand the nuances of compliantly billing the patient’s health coverage, or the patient themselves.
Navigating a Daunting System
Keeping track of these different rules in every state can be a daunting task. In the U.S., workers’ compensation is primarily administered at the state level, and the federal government has no oversight authority of state workers’ compensation systems. In 2022, there were approximately 3 million workplace injuries and around 5,500 worker fatalities reported across the country.1
Most healthcare providers do not have the resources to stay up to date on every state’s workers’compensation rules. For larger health systems in multiple states, knowing where an employer is located for the state of jurisdiction is also critical. To obtain proper reimbursement, healthcare providers must navigate a system in which the most common dispute outcome is, at best, underpayment, and at worst, denial of payment. The time and money healthcare providers spend to authorize services can compete with the revenue they’re trying to recover. And even with all the effort, the claims can still be denied due to inconsistent dispute rulings.
Proper Payer Discovery
Another key component is an effective discovery process to determine who the actual payer is. Injured patients often don’t know who their employer’s workers’ compensation carrier is when they present for services. Educating patients helps ensure the right data is collected to submit a clean claim to the carrier. Once the claim is billed and adjudicated by the carrier, the right vendor will evaluate if additional payment is owed based on the contract or fee schedule that applies to that claim. Appeals can ensure denied or underpaid claims are re-adjudicated to maximize reimbursement.
Many providers do not realize how much money they are leaving on the table because they accept the initial payment and adjust off the balance without further consideration. According to the National Council on Compensation Insurance, the average cost of a workers’ compensation claim in 2020-2021 was around $41,757, with the most expensive lost-time claims stemming from motor vehicle crashes, burns, falls, and machinery accidents. The construction industry consistently reports the highest number of workers’ compensation claims due to its inherent risks.2
A trusted RCM vendor can dedicate the time and possess the expertise to thoroughly vet the payment and ensure the claim is paid in full. While many facilities may have expected reimbursement or fee schedule detail built into their system, often those contracting modeling tools are not capable of capturing the detail and understanding the nuance needed to do a thorough analysis of the payment.
Leveraging Innovative Technology
Having the right technology allows for efficient management of workers’ compensation claims inventory, deadline tracking, billing automation, and claim statusing. Leveraging technology ensures efficiency and productivity, allowing staff resources to be reserved for those pieces of the process that require the human touch.
It’s important for an RCM partner to utilize a technology platform that integrates seamlessly with any host system and performs daily data transfers of claims and medical records. This ensures both the hospital’s system and the vendor’s account management system are reconciled. Technology should drive workflow and allow for efficient management of inventory and optimized revenue recovery, including identifying underpayments and facilitating appeals to ensure that payments are in line with the maximum allowed.
About Elevate Patient Financial Solutions®
Elevate Patient Financial Solutions® is a trusted provider of patient-focused revenue cycle management solutions, including Eligibility & Enrollment, Complex Claims, Denials Management, Extended Business Office Engagements, and Self-Pay/Early Out Services. With in-depth, state-specific knowledge and a coast-to-coast presence, ElevatePFS delivers exceptional performance and an unmatched client experience.
For decades, the ElevatePFS Workers’ Compensation model has delivered the people, process, and technology to help hospitals and health systems across the country improve cash acceleration. The complexity involved with this unique payer source not only requires specialized training on state regulatory requirements but also expert insight into the accuracy of payments and dispute resolution processes.
Since workers’ compensation accounts don’t coordinate with other payers, we focus on quick revenue recovery by eliminating all roadblocks. Our goal is to resolve 100% of WC accounts placed whether by recovering payment by workers compensation carriers or facilitating the billing of health insurance.
Resources
- https://blog.dol.gov/2024/03/08/record-profit-questionable-protections-the-state-of-workers-comp#:~:text=According%20to%20a%20new%20report,injured%20or%20sickened%20on%20thehttps://injuryfacts.nsc.org/motor-vehicle/overview/crashes-by-month/
- https://injuryfacts.nsc.org/work/costs/workers-compensation-costs/