Texas Workers’ Compensation … · Texas Workers’ Compensation Tips for Successful Medical Billing and Reimbursement Practices Texas Dept of Insurance - Division of Workers’

Texas Workers Compensation

Tips for Successful Medical Billing and Reimbursement Practices

Texas Dept of Insurance - Division of Workers Compensation 2012

Presented by: Regina Schwartz Health Care Specialist

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.

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Calls and Emails Received

85% from health care providers/facilities or their staff

15% from other persons, including insurance company representatives, attorneys, etc.

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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

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Patient

IntakeMedical Service(s) Billing

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.

Identify a Workers

Compensation Claim

and

Verify Coverage

Provide Medically Necessary

Treatments and Services

Refer to the ODG for

recommended treatments and

services for the patients

specific diagnosis/condition

Know what services require

preauthorization and that

preauthorization was

requested and approved (in

writing).

Processing a Workers Compensation Patient

What you need to

know to bill

correctly

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.

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

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Tip #1 Identify a

Workers Compensation Patient

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What are the risks in not knowing the patient is a workers compensation

claimant?

Missed billing deadline

Billed the wrong carrier/patient

Didnt get preauthorization

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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?

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Intake What You Should Ask

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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?

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Workers Compensation Coverage

EMPLOYER

Subscriber

Covered

Employers

Workers

Compensation

Insurance

Policy

Certified

Self-Insured

and Group

Self-Insured

Public

Employer

Intergovernmental

Risk Pools

and

Other

Required

Employers

Non-

Subscriber

(Not Insured)

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

How do I know if the patients employer has workers

compensation coverage?

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http://www.tdi.texas.gov/wc/employer/coverage.html

Call the DWC Insurance Coverage Department

800-372-7713, opt. 6

In Austin: 804-4000, opt. 6

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Whos the insurance carrier?

Is it a network claim?

Certified Workers

Compensation

Network

Certified under the

Texas Insurance

Code,

Chapter 1305

DWC Medical Fee

Guidelines

(non-Network)

Defined by Texas

Labor Code,

Section 413.011

Public Employer

Intergovernmental Risk Pools

Section 504.053

Direct contract

with health care

providers

Does the health care

provider have a

contract with the

network?

Tip #2

Understand the Use of the

Treatment Guidelines

and

When to Request Preauthorization

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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.

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 Divisions adopted treatment guidelines, and

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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

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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

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Approved treatment is not a guarantee of payment

Carrier can deny payment for compensability, extent of injury, relatedness to the injury, or liability issues

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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

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

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Example

Non-emergency health care requiring preauthorization

(12) treatments and services that exceed or are not addressed by the commissioners 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);

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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

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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

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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

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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

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.

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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


Requirements

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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 Divisions preauthorization list in 134.600.


Requirements

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.

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Tx

recommended

for your patients

specific

condition?

Tx on

preauth

list?

Provide

Treatment

Subject to

retrospective

review of

medical

necessity

Diagnosis

in

ODG?

Request

Preauthorization

No Yes

Yes NoYes

No

Request

Preauthorization Request

Preauthorization

Tx

exceed

guidelines?

Yes

Request

Preauthorization

No

Typical Treatment / Preauthorization Decisions

Tip #3

Stay Current with Changes from Centers for Medicare

and Medicaid Services (CMS)

Labor Code 413.011

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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.

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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

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

Medicare Biller Workers

Compensation Biller

A good resource for the workers compensation biller is the person who bills for Medicare.

What would

Medicare do?

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/

External Resources (CMS and MACs)

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

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http://www.novitas-solutions.com/http://www.novitas-solutions.com/http://www.novitas-solutions.com/

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

External Resources (CMS and MACs)

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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.

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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

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Preauthorization & Concurrent Review

Texas workers compensation payment policy rules work in conjunction with other Division rules

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).

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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,

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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

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Carriers request for additional

documentation

Rule 133.240

Deadline: Not later than the 45th calendar day after receipt of the medical bill

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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

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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

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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.

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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.

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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.

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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

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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

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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)

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Why was the bill denied?

What did the EOB say?

Compensability/

Extent of Injury/

Liability

Not medically

necessary

Fees reduced

or denied

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

Reconsideration 10

months from the

DOS

Rule 133.250

Reconsideration 10

months from the

DOS

Rule 133.250

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

Preauth approved-

bill denied for no

preauth

Preauth approved-

bill denied form lack

of medical necessity

Not a prerequisite

for filing for

subclaimant status

Determining the Appropriate Disput Path when Your Fees are Denied or Reduced

(Non-Network Claims)

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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

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Health care provider to request

reconsideration for a preauthorization

that was denied

Rule 134.600

Deadline: 30 working days of denial

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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.

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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

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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

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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 of the IRO fee

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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

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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 employers 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 restrictions.

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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

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Need Assistance?

General Information about Medical Services

Submit question to

[email protected]

Subscribe to eNews

http://www.tdi.texas.gov/alert/emailnews.html

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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]

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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

Inquiries on Active/Closed Medical Fee Disputes

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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.

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http://www.tdi.texas.gov/wc/rules/index.html

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.

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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 TDI-DWC staff. The comments are used in preparing the rules for formal proposal for public comment.

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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 TDI-DWC staff. The comments are used in preparing the rules for adoption.

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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.

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Any Questions?

Documents

Texas Workers’ Compensation … · Texas Workers’ Compensation Tips for Successful Medical Billing and Reimbursement Practices Texas Dept of Insurance - Division of Workers’