Every year, an estimated 3.5 percent of full-time employees in the United States make worker’s comp claims to pay for medical treatment for work-related illnesses and injuries. For small clinics that regularly provide care for these patients, problems with worker’s comp claims can quickly lead to major problems. Not only do patients get upset when a worker’s comp claim is denied or an objection is filed, but dealing with the situation can also disrupt your revenue cycle and prevent you from meeting your goals for A/R days.
Workers comp claim denials and objections can generally be grouped within three categories: U/R denials, MPN issues, and OMFS-related problems. Read on for more information about each one.
U/R denials are denials that result from the health insurance company’s Utilization Review (U/R) process. This means that the worker’s comp claim was reviewed, and the insurance company found a problem. For instance, they may have determined that the services were not covered or that the treatment provided was inappropriate based on the nature of the patient’s work-related health condition. Either of these cases could lead to a claim denial or objection.
An MPN (Medical Provider Network) is a group of health care providers that are contracted with a health care plan to offer services at specific rates. Some self-insured employers and worker’s comp insurers have an MPN, through which an employee is expected to get care when making a worker’s comp claim. Any confusion about whether or not an employee did so can lead to an objection or claim denial.
The OMFS (Official Medical Fee Schedule) is a body of legal documents that lays out important information about worker’s compensation for different services. However, changes are frequently made, so OMFS-related problems often arise. For example, in 2016, changes were made to the physician and non-physician services fee schedule, the DMEPOS fee schedule, and the pathology fee schedule. If there is any miscommunication about the reimbursements a claim denial or objection could arise.
If your clinic is facing claim denials and objections, the best way to handle the situation is to get an expert collections team on your side. An expert collections team can address U/R denials, MPN issues, and OMFS-related problems by demanding full payment, with support from case law and the labor code. That way, your clinic can avoid hassles resulting from worker’s comp claims.
AnnexMed has an excellent workers comp collections team, and we can help you with a wide range of other billing and coding issues. Contact us today for more information!
- Posted by admin
- On January 10, 2018
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