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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.

Consequential Injuries May Be Covered Under Original Workers' Compensation Claim

Tuesday, February 06, 2018

Mr. M had a work related left leg injury.  He would go up and down the stairs using only his right leg.  He could only sleep on his right side.  He started using a cane on his right or “good” side to relieve the pressure and provide security against falls due to the imbalance his left leg injury had caused.  Then his left shoulder started causing him pain.  He had trouble buttoning his shirt and reaching for items in the kitchen cabinets.  Just my luck, he thought, now I have gone and done something to my shoulder.  After several months he was sitting with his lawyer discussing his workers’ compensation treatment for his left knee and he mentioned how it feels as if his body is falling apart.  After a few strategic questions from his lawyer and a visit with his doctor it was determined that the shoulder was related to his original workers’ compensation injury to his left leg.  The use of the cane caused additional pressure and strain on his shoulder.  Mr. M was able to have covered workers’ compensation treatment and an additional monetary award due to the shoulder strain.

When Will The Insurance Company Cover My Secondary Injury?

Similar to Mr. M many injured workers’ do not realize that if their secondary injury is causally related to the initial accident then that consequential injury may be compensable.  Consequential injuries are those injuries that occur directly as a result or consequence of an injury to a different body part.  For example, if a compensable knee buckles and causes a fall, which injures a wrist the wrist injury could then be deemed compensable.  It is important to document any of these consequential injuries whether at work or through a medical professional. Your attorney will work with you to gather the necessary medical documentation to prove that the injury is related to the original claim.  Then a hearing in front of the commission may be required to prove causal relationship between the secondary injury and the original injury.

Can I File For a Consequential Injury At Any Time?

Since there are statutes which impose limitations on when claims can be filed for additional injuries it is best to alert your attorney as soon as possible.  However, if the statute of limitations has run on earning additional compensation for the secondary injury it is still important to still talk to your doctor and your attorney about the injury.  Even if you are not entitled to additional money, you could be entitled to coverage for medical expenses and mileage related to your consequential injury.  It is always best to speak with your workers’ compensation attorney as soon as possible.  Many times in my practice clients only reveal the consequential injury after the statute of limitations has run or once it has become unduly burdensome, however if we handled your original claim I will handle your consequential injury even if no additional money can be earned.

The Importance of Documenting All of Your Injuries

Tuesday, July 18, 2017

All too often when workers are injured the focus is on the most severe parts of the body hurt. Frequently the minor pains and bruises from other parts of the body are ignored. However, in a workers’ compensation claim it is very important to report every hurt, bruised, or swollen body part no matter how minor it may seem at the time. The human body is interconnected and when you fall, for instance, you may land on your knee, but your hands may have eased the impact, which can cause shoulder and arm pain as well. If you injure your back, the nerve pain and/ or damage can cause problems in your legs. You may not feel any symptoms to those other areas until a day or two later, but these are all parts of your body that could get worse over time and require additional medical treatment. It is important in a workers’ compensation claim to document every part of the body that was affected by the accident no matter how small it may seem. It is more difficult to try and convince a Commissioner or insurance company that another body part was also injured in the same accident if there is no documentation of it within a few days of the accident.

What’s In The Injury Report Matters

This rule is important to remember when filling out your accident report at work, your workers’ compensation claim form, and any forms you are given at every medical office you visit after the accident. In our practice, we frequently read emergency room reports where an injured body part is left out or the wrong body part is documented. We all know hospitals are busy places and not everything is always documented with 100% accuracy, but insurance companies will use this to discredit your injury or the cause of your injury. It is important for you to check that how the accident occurred and that all injuries are clearly described and documented. Make sure to tell the medical professional you are dealing with every ache, pain and/or discomfort that you are feeling as a result of the accident.

Contact Us With Questions

If you have any questions about a new pain or problem that developed after your injury it is always best to contact an attorney. Our attorneys have years of experience and know the right questions to ask to ensure that you receive the full coverage, you are entitled to for your injuries.

I was told I have lifetime medical coverage, under workers' compensation, but they are denying my claim!

Friday, September 23, 2016

The Law. Many injured workers remember that towards the end of their case, when they settled, received a lump sum award, or weekly payments for a set period of time for their workers’ compensation claim, they were told that there right to medical treatment was left open for the duration of their life. However, of course, this comes with a caveat; according to the Workers’ Compensation Law of Maryland, injured workers are entitled to medical treatment with no time limitation, unless stipulated otherwise, for the body part that was injured at the time of the accident as long as the requested medical treatment is reasonable and necessary and is casually related to the original accidental injury.

What does this really mean? For continued medical treatment the injured worker must prove that their current need for medical treatment is still related to the original claim. Thus, the insurance company may not approve any treatment without a doctor’s letter stating that the current need for treatment is still related to the original claim. In my practice, clients often call me after two (2) - five (5) years of feeling fine and now have an onset of the same symptoms they felt several years ago from their accidental injury or disabling occupational disease. Injured workers are often frustrated that their employer’s insurance company will not automatically approve a visit or treatment. This is compounded when the injured worker finds out that before treatment is approved, the employer’s insurance company is allowed to send them to the insurance company’s own “independent” medical evaluation, which often times will state that the current need for treatment is no longer related to the claim. When there has been a large gap in time from the last date of treatment until the present need for treatment usually an injured worker must participate in a hearing to request the Commission to order the treatment or visit. Scheduling of these hearings can take several months.

What should I do? First the insurance company needs evidence through medical reports that the new symptoms are related to the original injury. Then the insurer will need to verify that the requested treatment is reasonable and necessary. Finally they will investigate to ensure there was no intervening event or accident that might have caused the onset of new symptoms. The best way to get your treatment as quickly as possible is to visit your doctor and ask them to write a letter that describes what treatment has been recommended, why the treatment is recommended and whether or not it relates back to the original Workers’ Compensation claim make sure all of your providers have your workers’ compensation insurance claim number and send reports and bills directly to the insurance company to ensure time is not lost in updating the workers’ compensation insurance file. In addition, verify that your attorney also has all of the appropriate recent medical reports, thereby supporting the effective and expeditious advocacy on your behalf. If Berman, Sobin, Gross, Feldman & Darby LLC was the law firm you used for the original claim we will continue to fight to get the medical treatment you need.

For More Information, Contact Attorney Julie Mirman 301-740-3306

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