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Workers' Compensation Blog

Who Pays the Bill? Medicare or Workers’ Compensation?

Wednesday, October 31, 2018

Upon reaching the age of Medicare eligibility confusion abounds when determining if Medicare is the secondary or primary payer, especially if you have a prior workers’ compensation injury. Requirements have become more stringent on the workers’ compensation insurance companies to report claims to Medicare. As a result more recipients are receiving what is called conditional payment letters. A conditional payment from Medicare is a payment made even though it is another insurance company’s responsibility, of which they may seek reimbursement from the appropriate insurance company or the beneficiary.

Why does this happen and how will it affect you?

Primarily this occurs because it is easier for a provider to bill Medicare; all the systems are in place and they promptly pay their bills. Where the hospital is concerned Medicare might reject the claim as workers’ compensation related, even if there is no logical or medical connection to a prior workers’ compensation injury. In addition, once Medicare is notified that a workers’ compensation claim exists you may receive a letter in the mail from Medicare stating that they were notified that you have a workers’ compensation award. In the early stages this is purely an investigation by Medicare to determine if they paid for medical treatment that is actually the responsibility of the workers’ compensation insurance company. If Medicare determines through their own investigation that they have paid for treatment unnecessarily or made a conditional payment, they will seek reimbursement from the insurance company. Medicare may also sometimes seek reimbursement from the beneficiary and will notify them in the form of a conditional payment letter.

How do I know if it is a workers’ compensation related condition?

Another confusing situation is when you go to the doctor or hospital for what you thought was acid reflux, an unrelated condition, and it turns out you have hypertension, a related condition. Or when you go to the hospital for a heart condition, which is related, and the prognosis is instead an unrelated gastric condition. The priority is always to receive the medical treatment needed and then deal with who pays the bill afterward. It is imperative to retrieve all the medical records related to the condition and hospital stay from the hospital. These are documents that are specifically requested following your visit. This is not discharge paperwork, but the actual doctor notes and work-ups from your stay and/or visit. It is also helpful to ask your physician to comment specifically in the paperwork if in their medical opinion the condition is related to a prior workers’ compensation injury or it is unrelated. Finally, the notes should indicate the final determination of your diagnosis. Then, these documents can be used to help Medicare and your workers’ compensation insurance company determines the proper payer.

What do I do if I receive a letter from Medicare?

If a beneficiary receives a conditional payment letter it is important to respond in a timely manner indicating if it was in fact a workers’ compensation related medical expense and to include supporting documentation. Supporting documentation can come in many forms either as a denial letter from the workers’ compensation insurance company or commission, a letter from the beneficiary’s doctor, or medical records and a letter of explanation from the beneficiary. This process is another reason it is important to insure that a doctor’s office or hospital is billing the appropriate insurance company to save the beneficiary hours of work on the back end. However, the most important thing is to not panic. Remember it is a bureaucratic process that changes frequently and it is always a good idea to send a copy of the letter from Medicare to your attorney to review and to guide you in your response. If you are a previous client or current client with our firm we provide this service to you at no charge.

Why is it taking so long for my medical bills to be paid?

Wednesday, October 10, 2018

HCFA Forms

Maryland Workers’ Compensation laws require that medical bills be submitted on HCFA forms. These are standard billing forms used by most insurance companies that have fields for the appropriate and necessary CPT (current procedures terminology) codes. However, some practitioners may not be aware that this is a requirement for workers’ compensation claims or that the bill may be denied if it is not submitted properly on the HCFA form. The adherence to this rule varies between insurance companies, however if your provider is having trouble getting bills paid then the first step should be to ensure that the bills are submitted on HCFA forms. As an easy reference the workers’ compensation website provides a blank downloadable HCFA form.

Itemized Billing

Another reason your workers’ compensation medical bills are not getting paid could be that the bill that was sent to the insurance company was not itemized with the proper CPT codes. The workers’ compensation carrier cannot pay bills that are not properly itemized with these specific codes, similar to the codes that a primary care physician would provide to a private insurance company. In addition, many carriers also require that each office visit note from the billed dates of service are provided with the bill. This requirement is to ensure that the visit was related to a compensable body part or condition. Where the system fails is when the carrier denies payment of the medical bills and does not site to the reason it is denied. Often it is a clear case of one department not providing the proper medical records to the carrier’s billing department. Instead of working together the billing department denies the payment of the bill. To resolve this confusion and to save time our firm often will attach the appropriate medical report when sending in any reimbursement or bill pay request even though the carrier may have previously received the report.

Collections Letters

When a medical bill has not been paid, for various reasons, the provider will often send the bill to a collections agency or will seek payment from the claimant. It is important to know that a provider has their own course of action within the workers’ compensation commission to collect on bills for approved medical treatment. This is done through submitting a C51 claim for medical services to the commission. The commission will then issue an order nisi to the carrier requiring payment of the bills. The provider can request penalties, fees and interest if the bill is unpaid for over 45 days and the carrier failed to provide written communication of the denial. In addition, a claimant may notify the collections agency or doctor’s office that under Sec. 9-660, Labor and Employment Article, MD. Ann. Code, medical expenses related to an accepted and related workers’ compensation claim should be directed to the workers’ compensation insurance carrier.

Contact your Attorney

Facilitating payment of medical bills is one of the services we provide to our current and past clients for workers’ compensation cases we have handled. If you have not filed a claim for medical services that you feel are related to a workers’ compensation claim please contact our office as soon as possible so that we may assist you before these bills effect your credit.

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