Managing Workers’ Comp Claims for Infusion Services

Written by: Brenda Langlais on Tuesday, February 23, 2016 Posted in: Home Infusion


lady-long-listInfusion billing is complex, but when the billing has to go through worker’s compensation—because the infusion services were required due to workplace injury—an additional layer of complexity is added. For starters, documentation requirements may vary from state to state, as do billing guidelines and rates. Here are some tips to help you overcome the challenges of workers’ compensation billing, for your infusion meds and services.

Before you embark on this process, visit the Department of Labor’s website for Office of Workers’ Compensation Programs (OWCP), and check your state’s website for specific guidelines. A thorough intake process is the key starting point.

Step 1

  • Receive referral for new patient
  • Ask key question: Is this a result of an accident or injury?
  • If yes, the services are required due to a work-related accident or injury, collect the following information:
    • Patient name and date of birth
    • Diagnosis for treatment specifically related to accident or injury
    • Employer’s name and telephone number
    • Date of incident (accident or injury)
    • Name of workers’ comp carrier, phone number and claim number
    • Other treatments the patient has received as a result of this injury
    • NOTE:  Make sure you get the patient’s health insurance information as well, in the event that the claim is deemed unrelated to the work-related accident
  • Set-up in system
    • Enter the workers’ compensation carrier as the primary insurance in the system. Enter health insurance information under secondary payer, if you are able to. Otherwise, enter information in reimbursement notes. Be careful that health insurance is not entered in as primary payer.

Step 2

  • Contact the workers’ compensation carrier
    • Obtain adjuster’s name, telephone number, and fax number
    • Obtain utilization review’s (UR) telephone number and fax number
    • Send a request for treatment authorization to UR, who should respond within 24-48 hours. UR will likely work with the adjuster to obtain an authorization. If UR approves, then adjuster must authorize payment unless adjuster denies based on state (UR is reviewing for medical necessity only)
    • NOTE:  In many states, regardless of the workers’ compensation carrier, there are fixed rates and standard codes. However, in other states, you will need to contact the adjuster to negotiate a single-case agreement and to determine which codes to use for billing. Drugs are typically billed using the “J” code and/or NCD code or a combination of both. Supplies may be billed using either the “S” code or the “A” code, depending on whether or not the workers’ comp carrier will be using the Medicare or Medicaid fee schedule and coding schematic. We recommend that you negotiate a daily rate for the drug and a per diem rate for the supplies. There are typically no standard contracts for workers’ compensation. Document the specific negotiated rate in your system so that both intake and billing/collections have easy access to the rates and codes for future reference and to be sure that the claims are booked as expected.
    • Obtain as much documentation as you can to substantiate the diagnosis and how it is related to the work-related accident. This includes, but is not limited to:
      • Prescriptions/orders/DWO
      • Single-case agreement, if applicable
      • Hospitalizations, surgeries, etc.
      • A detailed account of the accident including where, when, how, and what happened

Billing and Collections

  • Obtain negotiated rate/single-case agreement (if one exists) from intake
  • If negotiated rate does not exist, always bill at list and book at net (What you expect to receive from history of other claims that were processed. In some instances, the workers’ compensation carriers are paying 113% of Medicare allowable, and in other cases, they review the networks in which you participate and reimburse at the lowest rate in your network.)
  • Bill “J” codes for drugs and “S,” “B” or “A” codes for supplies (Some carriers require Medicare codes for claims)
  • Make sure claim form is complete, including the box checked for work-related accident
  • If the worker’s compensation carrier has an electronic payer ID, you can send electronically; however, you will find that most of these claims must be sent on paper
  • If you must send on paper, you should inquire to which, if any, attachments should be included. While paper claims require manual overview, you don’t want to send attachments just to send because this will only create delays and, in most instances, the services are already approved for medical necessity along with the payable amounts

As you do with most other payers, follow up a minimum of every 30 days until the claim is paid in full. If you are reimbursed less than expected, be sure to inquire how the payer arrived at the reimbursement rate. Often, infusion drugs are short paid due to confusion about how it should be billed (actual NDC vial, versus HCSPCS units, etc.). But by following these steps and your state’s guidelines, you can maximize your reimbursement. See how you can streamline your infusion billing with Mediware Reimbursement Services outsourced collection services.


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