How Doctors Are Paid For Treating Workers' Comp Claimants

Getting medical bills paid has become very complex. Billing for treating injured workers is no exception. This article offers guidelines in how you are paid for treating injured workers. You may wish to give this information to your billing office. The form required for billing is either DCBS Form UB-92 or Form HCFA-1500, “Health Insurance Claim Form.” You should have copies of these forms. The Workers’ Compensation carrier (“insurer”) has to accept or deny the worker’s claim within 90 days. No money will be sent to you until the insurer has decided to accept. Send correct and complete bills to the carrier/insurer in a timely manner. Note that doctors may not take any collection action against an injured worker so long as the claim is in litigation. When your patient’s claim is accepted, the insurer may not be required to pay your bill in full. The insurer is only required to pay the usual and customary fee for the medical service provided, according to the schedule (OAR 436-009-000 1, et seq.) issued by the Department of Consumer & Business Services (DCBS).

You DO NOT need to send a copy of the bill to your patient (“the worker”), UNLESS he requests in willing that you do so. If your patient’s injury is accepted, you MAY NOT bill your patient for the unpaid portions of your billed services. When your patient’s injury has been accepted, be sure to get a copy of the letter of acceptance so you know the condition which the insurer has accepted (the accepted condition”). This is important since your patient has a right to request acceptance of any condition related to the work exposure which the insurer omitted from the original acceptance. The insurer must consider such requests; and, if medically and legally valid, must issue an “amended acceptance” accordingly. This will help to insure that your bills are paid properly. What if the insurer is not paying your bills on an accepted claim? Contact the claims examiner and request payment.

Keep a precise log of all calls, including names, times and contents of the discussion. Call the DCBS Medical Review Unit at (503) 945-7849. They can be very effective. If the bill is not paid within 45 days of billing on an accepted claim, write to DCBS, Medical Review Unit, 21 Labor & Industries Building, Salem, OR 973 10, and request review of the matter. If your patient’s work injury claim is denied, you can bill the health care insurer, 9 any. Health insurers are required by statute to pay in these circumstances. Also, KEEP BILLING THE WORKERS’COMP INSURER EVEN AFTER A DENIAL since your patient may appeal. On appeal, if your patient obtains a reversal, your bills will be paid as for an accepted claim. Or, your patient’s claim may be settled on a “Disputed Claim Settlement’ (“DCS”) basis. When a DCS is entered, the insurer is required to pay a portion of any related bill they have in their possession. The insurer must pay up to 50% of the audited value of your bills. However, the maximum total amount allowed for medical bills is 40% of the net present value of the total settlement (“net settlement”). If 50% of the audited value of the medical services exceeds 40% of the net settlement, payment is pro-rated among all medical providers. It is critical that you keep billing the comp insurer, since only the bills that the insurer has received will he paid under a DCS! In DCS cases, you may recover from your patient the balance of the amount owing for your services. The “amount owing” refers to 50% of the audited value of your bills, not the total billed amount.

Insurance companies routinely deny benefits. Our law firm has your interests in mind. We will use our experience and skill to help you pursue the benefits you need to cover the medical bills you have incurred as a result of your workers compensation injury, and we help you seek disability benefits. Contact us today to speak with an experienced workers' compensation attorney. Our attorneys are interested in making sure you receive proper medical care and receive the workers' compensation benefits to which you are entitled. If you dispute the findings of the insurance company's doctor, we can help you seek the opinion of an "agreed medical examiner" who is independent of the insurance companies. If you are seeking workers' compensation benefits or are facing the denial of treatment, we can help. Contact us online or by telephone at 415-292-7800 to speak with an experienced California workers' compensation attorney. For your convenience, we offer free initial consultations. Our billing is strictly on a contingency fee basis: You don't pay us unless we win compensation for you. We speak Spanish, Mandarin, Cantonese and Tagalog.

Many people refer to the doctors who provide medical treatment for work injuries as workers compensation doctors. Some people use the term “company doctors”. In Georgia, injured workers are often told that they must go to the doctor that the employer or workers’ compensation insurance company chooses. This is not the case the case. Do Workers Compensation Doctors Actually Work For My Employer? Probably not. The doctors are picked by your employer to be on their list of doctors (otherwise known as the “panel of physicians”). However, that does not mean the doctor works for your employer. Your employer should have a posted panel of physicians (unless your employer uses a WC/MCO). This panel should have at least six doctors on it. The doctor that your employer sent you to is probably one of the doctors on the panel. Many employers use the panel of physicians to their advantage. They may pick doctors who are likely to say that you are not as hurt as you say you are. They may pick doctors who are likely to blame your problems on a preexisting condition instead of the work injury.