Special Handling Contacts the employer immediately when an injured worker presents for the first visit without a written or personal referral from the employer. Contact the workers’ compensation board of the state where the work-related injury occurred. No patient signature is needed on the First Report of Injury form, Progress Report, or billing forms. If an established patient seeks treatment of a work- related injury, a separate compensation chart and ledger/account must be established for the patient. The First Report of Injury form requires a statement from the patient describing the circumstances and events surrounding the injury. Progress reports should be filed when there is any significant change in the patient’s condition and when the patient is discharged. Prior authorization may be necessary for nonemergency treatment.
• Explain how managed care applies to workers’ compensation coverage.
Both employees and employers have benefited from incorporating managed care into workers’ compensation programs, thereby improving the quality of medical benefits and services provided. For employers, managed care protects human resources and reduces workers’ compensation costs. For employees, the benefits include:
● More comprehensive coverage, because states continue to eliminate exemptions under current law like small businesses and temporary workers
● Expanded health care coverage if the injury or illness is work-related and the treatment/service is reasonable and necessary
● Provision of appropriate medical treatment to facilitate healing and promote prompt return to work
● Internal grievance and dispute resolution procedures involving the care and treatment provided by the workers’ compensation program, along with an appeals process to the state workers’ compensation agency
● Coordination of medical treatment and services with other services designed to get workers back to work
● No out-of-pocket costs for coverage or provision of medical services and treatment; cost/time limits do not apply when an injury or illness occurs
• Describe workers’ compensation appeals and adjudication processes.
When a workers’ compensation claim is denied, the employee can appeal the denial to the state Workers’ Compensation Board and undergo adjudication, a judicial dispute resolution process in which an appeals board makes a final determination. All applications for appeal should include supporting medical documentation of the claim when there is a dispute about medical issues. If the appeal is successful, the board will notify the health care provider to submit a claim to the employer’s compensation payer and refund payments made by the patient to cover medical expenses for the on-the job illness or injury.
provides medical treatment and other benefits for respiratory conditions related to former employment in the nation’s coal mines= Federal black lung program
Understanding health insurance A guide to billing and reimbursement, Thirteenth edition; Michelle A green Chapter 17
Worker’s Compensation provides weekly cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury on the job. It also provides payments to qualified dependents of the worker who dies from a compensable illness or injury. To qualify for WC the employer must be injured while working within the area of the job description, injured while performing a service required by the employer or develop a disorder that can be directly to the employment such as mercury poisoning.
Workers’ Compensation cases are handled special because providers are required to accept the workers’ compensation-allowable fee as payment in full for covered services rendered on cases involving on-the-job illnesses and injuries. An adjustment to the patient’s account must be made if the amount charged for the treatment is greater than the approved reimbursement for the treatment. I used to work in an Orthopaedic Office where we had a lot of WC cases that covered the office visit, therapy and possibly surgery if needed.
Managed care applies to WC coverage in a great way. Both employees and employers benefit from incorporating managed care into WC programs, by improving the quality of medical benefits and services provided. For employers, managed care protects human resources and reduces WC costs. For employees some of the benefits are:
When a WC claim is denied, the employee can appeal the denial to the state Workers’ Compensation Board and undergo a process when a judicial dispute resolution process in which an appeals board makes a final determination = adjudication. During the appeal process, involved parties will undergo a deposition, a legal proceeding during which a party answers questions under oath. If the appeal is successful, the board basically notifies the health care provider to submit all the claims for the employee to the WC payer and refund the payments made by the patient.
Understanding Health Insurance A Guide to Billing and Reimbursement 13th Edition