whether to accept a worker's comp offer

[James B]

We are in CT and treat a patient for issues related to his accident--depression and opiate dependence. 
I recently billed Liberty Mutual on a CMS 1500 form (had to fax bill to them, as opposed to electronic submission which is our normal method) and they have offered the Dr. $5200 for a $8000 claim. The Dr. has been in practice 30 years but in that time hasn't dealt with WC much, and we are wondering what alternatives we have to accepting their offer. In other words, what if we don't accept it? I did do a forum search but couldn't find a similar question. Any suggestion/resources would be greatly appreciated.

Best,
James

[DMK]

In most states there is a fee schedule for W/C.  They usually pay better than private insurance, but never 100% (as some PI does).  I would check first to compare your fees against the set fees for your state.  Also look for "cascades".  In California you get 100% of the 1st procedure (at the state's fee schedule) then 75% of the second procedure...etc.

Second, did you have prior authorization to treat this patient?  If yes, they do have to pay, but only up to the state's fee schedule unless you had prior arrangements.  If no, they don't have to pay you at all, you may have to go to court to get it.

So there are a few things to weigh.  The doctor performed his services and absolutely deserves to get paid.  The only question is what do they HAVE to pay?

I hope this helps.  You may want to google Worker's Compensation Fee Schedules for CT.

[rdmoore2003]

I agree with DMK.    You must find out what your state allows for each cpt code that you use.    for example, my provider set his rates for all services that are comparable to our states wc fee schedule.   if you did not have an authorization for the services, good luck, you may eat that charge.  you may have to send everything to the patients wc attorney if they have one, to see if maybe they can get an auth and/or payment for you.  now, you are required to complete a 1010 form when getting an auth, this is much easier for me for a papertrail with the wc's.

[James B]

Thanks alot, DMK and rdmoore.

The amount they offered is 65% of what we billed so, yes, it's better or equal to what some private insurance companies pay but not 80-100%, which we would naturally prefer. I looked for the fee schedule for CT as you suggested and it appears that it was updated in July and can only be purchased through its exclusive publisher for $125 (the CD, as opposed to the book option, says 'call' so maybe it is cheaper). What a pain. Perhaps if I keep searching I can find some info re: the codes we bill for, though. And, yes, I believe that either we have a pre auth or the patient is allowed to chose his doctor, or both. I'll have to check with the doctor, but they ins. has not denied our claim so this doesn't seem to be an issue.

Thanks again, very helpful.

[PMRNC]

Just a tip but I do mental health billing as well and claims regarding alcohol and drug addiction in relation to a WC injury is a PAIN IN THE REAR END... In many cases if you take the case on assignment you will WAIT WAIT AND WAIT..because they investigate them claims (seems natural).  I tell my doctors NOT to accept assignment on these UNLESS they look into the case and a LOP (Letter of Protection) is received from patient's attorney.  Those cases take a long time because it's hard to PROVE chem dep / any addiction is "RESULT" of an open case/injury.  The fastest ones I've seen are related to PTSD and Trauma cases.