Workers comp billing: payer, auth, and documentation

Workers compensation covers medical care for work related injuries and illnesses. It is not health insurance. Each state runs its own system, with its own forms, fee schedules, and rules, and the employer's workers comp carrier pays the claim. Practices that bill workers comp like ordinary health insurance often wait a long time for payment.

Start with the right payer

The patient's health plan is usually not the payer for a work injury. The employer's workers comp carrier, or a third party administrator acting for it, is. Billing the health plan first can lead to denials and payback requests later.

• Employer name and contact.
• Workers comp carrier or administrator, with the claim number.
• Date of injury and a short description of how it happened.
• Adjuster or case manager name, phone, and fax.
• The body parts accepted on the claim, if known.

Authorization and the accepted claim

Many workers comp carriers require authorization before treatment, especially for therapy, imaging, procedures, and referrals. Payment is also tied to the injury the carrier accepted. Treatment for a body part or condition that is not on the accepted claim may be denied. Confirm what is authorized and what is accepted before scheduling care beyond the initial visit.

Documentation workers comp payers expect

• Clear notes that connect the treatment to the work injury.
• Work status and restrictions, using the state's forms where required.
• Progress reports on the schedule the state or carrier requires.
• Records sent with the bill when the state or carrier asks for them.

Billing rules differ by state

Most states publish a workers comp fee schedule and billing rules, including which claim form to use, filing deadlines, and how to dispute a payment. Some states require specific forms for reports or work status. Check the rules for each state where your patients are injured.

Common reasons workers comp claims stall

1. No claim number, or the claim is still under investigation.
2. Treatment not authorized, or authorization expired.
3. Body part or diagnosis not accepted on the claim.
4. Missing reports or work status forms.
5. Wrong payer or address for the carrier or administrator.

Follow up and reporting

Workers comp AR should be tracked separately from health insurance AR, by carrier and by claim. Regular contact with the adjuster, and a record of each call, helps resolve delays before they become write offs.

Questions to ask at intake

• Did the injury happen at work, and has it been reported to the employer?
• Is there a claim number yet?
• Who is the adjuster or case manager?
• Has the carrier approved this visit or referral?

Where Afiable helps

Afiable bills workers comp with the right payer, authorization, and documentation checks, follows up on delays and denials, and reports on open workers comp AR. Book a free audit and we will review your open workers comp claims and show you what is holding them up.

This article is general information for practice owners and managers. Payer policies and regulations change, so confirm current rules with each payer before acting.