Physical Therapy & Workers’ CompensationThe Workers’ Compensation billing process can frequently be overwhelming for physical therapy providers because of demands on documentation, follow up, and the occasional claim appeal with the payer to have funds reimbursed. And even after all this, some payers can still deny the claim or fail to respond.

Workers’ Compensation clearly offers critical financial support to injured workers. Key to getting a workers compensation claim approved is getting facts right and providing proof to back the claim. This blog post will discuss some of the challenges in Physical Therapy and Workers’ Compensation for submitting claims and getting paid.

Physical Therapy and Workers’ Compensation | Challenges

Speed matters

Physical therapists may have to deal with special terminologies, unique processes, plus occasional legal obstacles for Workers’ Compensation. Furthermore, when it comes to filing a claim, time is of the essence. Claims are to be rapidly filed to reduce the chances of denial. With all the documentation required, it will be a race against time. All these factors could lead to denial or delay of Workers’ Compensation payments.

Manual documentation

Some payers may continue to rely on manual documentation of Workers’ Compensation claims, which can be daunting. Compliance with state regulations for Worker’s Compensation is obviously crucial. Although the billing process differs from one state to the next, nationwide billing guidelines for Workers’ Compensation claims keeps billing fairly uniform.

With manual billing for worker’s compensation, the CMS-1500 claim form and First Report of Injury Forms come in handy. The physician completes the First Report once the patient seeks treatment for the first time after sustaining an injury in the workplace. The CMS-1500 claim form needs to be submitted together with the physician’s documentation to the payer for reimbursement. The injury date needs to be included on the CMS-1500 form.

Failing to receive a response after submitting worker’s submission claim

Cases of no response after submitting and re-submitting worker’s compensation claims are fairly common. Even after follow-up, the result may not always change.
Other issues could be:

  • The physical therapy practice failing to set up an online portal for submitting Workers’ Compensation claims.
  • Lack of EFT/ERA setup for Workers’ Compensation to receive electronic payments.
  • The physician’s office sometimes taking longer than usual to release the patients’ medical reports.

Physical Therapy and Workers’ Compensation | The Solution

Physical therapy providers can reduce Worker’s Compensation claims rejections or delays by embracing automation, robust electronic billing practices that are implemented using practice management software platforms.

Electronic billing will not only reduce the cost and time spent on Worker’s Compensation billing processes, but it will also shrink the payment cycle and improve interaction between the payer and physical therapy providers. Furthermore, with ERA/EFT setup, it becomes easy to receive payments electronically.

Worker’s compensation laws in the United States vary including how funds are reimbursed, the amount received, and the process of submission of claims. Below are some of the states that have transitioned from manual to electronic submission of workers compensation claims.

New York
The Workers’ Compensation Board of the New York State has urged all on board, payers, and authorized Healthcare Providers to switch to electronic submission through CMS-1500 form from 1st July 2021. The board instructs administrators to start preparations right away. Also, it has uploaded vital information on its website to facilitate the change.

The Alabama Labor Department Workers’ Compensation Unit expects to receive a fully completed WC-4 Claim form for all Workers Compensation reimbursements in Alabama irrespective of whether the reimbursement is presented before an ADOL Ombudsman or a Circuit Court Judge.

For physical therapy providers who have opted for electronic submission of Workers’ Compensation claims, Division Rule 16-9 (E) outlines how providers can provide proof of timely filing in case of a dispute. For claims sent through electronic data interchange (EDI), providers can prove that the claim was filed on time by providing a payer acknowledgment. Keep in mind that clearinghouse acknowledgment reports or rejected claims reports are not considered evidence for timely filing.

In Florida, medical bills can be electronically submitted on the condition that the insurance carrier approves.

All health practitioners attending to workers injured at work and submitting claims for worker’s compensation are expected to submit medical bills for reimbursement on standardized forms on paper or electronically.

Electronic billing was made compulsory in Minnesota in 2009. All health practitioners, excluding the hospitals, are expected to send medical records electronically.

North Dakota
In North Dakota, electronic billing was passed on 7th January 2021. The state acts as the sole insurer for Workers’ Compensation. WSI manages the billing and reimbursement process. Also, North Dakota’s approach to worker’s compensation contrasts with Workers’ Compensation structures of other states. WSI approves 837P and 837I EDI transactions via Carisk Intelligent Clearinghouse — a customized clearinghouse that facilitates electronic submission of medical bills.

Oregon and Washington States
For providers, electronic billing is optional but compulsory for payers. In Washington, electronic billing became mandatory as of 1st January 2020.

Forms submitted electronically are accepted depending on payer capabilities. This includes Compulsory Electronic Data Interchange for FROI (First Report of Injury) and SROI (Subsequent Report of Injury).

According to Workers’ Compensation Virginia laws, all workers’ medical bills alongside essential documentation should be sent electronically via a clearinghouse. Also, payers should approve medical bills sent in line with set standards.

New Jersey
Billing representatives or healthcare providers that process more than 25 claims every month should submit Workers’ Compensation and no-fault auto bills plus necessary documentation electronically. They must also stick with all set guidelines. Providers with less than 25 auto insurance Carriers or Workers’ Compensations, third-party administrators, or medical management companies should approve electronic bills.

Physical Therapy and Workers’ Compensation | Path Forward

Electronic billing of Workers’ Compensation claims is clearly the path forward for physical therapy practices. Physical therapy practice management / billing software can track the entire process and make it easier to manage it, enabling you to stay informed on the status of your submission from the initial assessment to the last stage. As always, physical therapists can choose to automate the way out of the challenge.