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Workers’ Compensation Provider Payments

Ask a medical practice biller which insurance payer is the most frustrating to handle and the answer is almost always workers’ compensation. Here are some suggestions for turning workers’ compensation into a viable business in your practice.


After reading this article you will know how to:

  • Summarize the essentials of billing workers' compensation
  • Describe staff roles in claims management
  • Identify pre-appointment information needs

View related pearls


Ask a medical practice biller which insurance payer is the most frustrating to handle and the answer is almost always workers' compensation. Yet, for many practices, this particular payer may comprise a significant segment of the bottom line – perhaps even a lucrative one despite all the paperwork and other hassles.

First, a bit of background about workers' compensation: This payer is actually 50 small entities. Workers' compensation is administrated by states, each of which has different rules, regulations and, of course, fee schedules. It's impossible to generalize about workers' compensation, other than the fact that challenges abound regardless of the state.

In some states, the program is beset by poor management, lack of resources, and archaic protocols. Other states have upgraded to electronic systems and instituted more efficient claims management processes, but challenges seem to be ubiquitous throughout the country. Reimbursement rates vary widely among the 50 states, and remarkably, a few states have no fee schedule. That is, they pay claims with reimbursement amounts seemingly based on whim. Another factor to consider with workers' compensation is that plans are often exempt from state prompt payment laws.

While it's tempting to ignore this line of business, workers' compensation is an important player in the health care market. Depending on your specialty, it might be a payer that can contribute meaningfully to your practice's bottom line. The trick, experts say, is to be prepared.

Here are some suggestions for turning workers' compensation into a viable business in your practice:

Identify early. Like other aspects of the revenue cycle, successful management of workers' compensation requires efforts at the time of service. The key is to identify a workers' compensation case as it presents – not after the service is rendered. To avoid the need to backtrack (a surefire way to not get paid), implement a protocol in your front office to ask every patient presenting with an injury if it happened at work.

If the patient indicates that the injury is work-related (or even hints at that fact), gather the important details, including the case number, date of injury and name of the claim or case manager assigned to the patient. If these aren't yet available, at minimum, capture the date of injury (important for the patient's care, too) and the employer. Gathering these details may slow the check-in and registration of new patients but they are critical items for avoiding a potentially expensive denial.

Assign schedulers. Appointment schedulers are the front line for capturing information from patients and reducing the time spent gathering information at the front office on the day of the appointment. Provide them with a template that serves as a reminder of the questions to always ask patients who call for appointments.

Make it a standard protocol to ask every patient calling in for an appointment, regardless of their insurance, if the visit is due to a job injury, particularly if you are in a practice which commonly treats work-related injuries. If the response is positive, it may take 10 or 15 minutes extra for the scheduler to obtain that needed information over the phone but the alternative is to risk getting stuck with the tab for the patient's services.

Contact the employer. Before the first visit from a patient using workers' compensation, contact his or her employer. At the very least, you will be able to find out if the employer participates in the state's workers' compensation insurance plan and whether a report of first injury form has been completed and filed properly. Do not share claims details, treatment plans or other medical information with the employer as it may be a violation of HIPAA rules designed to safeguard patients' protected health information (PHI).

Know the rules. Understand what workers' compensation will and won't pay for. Frequently, this information is included on an authorization form available from the nurse case manager or adjuster. If you do not see it on the authorization, chances are you won't be paid for it. Obtain a written authorization for the treatment(s) you wish to perform. Be sure also to keep the billing for workers' compensation-related treatments separate from the billing for any other complaints the patient may bring up during visits. Although not required by regulation, it's a good idea to maintain documentation in the medical record separately as well.

Keep track of fee schedules. Pay extra close attention to payer reimbursements, especially when fee schedules change. It is not uncommon for the private payers administrating workers' compensation claims to neglect to adjust their fee schedules correspondingly after the state authorizes an increase in reimbursement rates. If you are committed to making workers' compensation a viable business line, then prepare to invest in keeping track of changes in rules and fees and know how to chase down every dollar you are owed.

Develop relationships. Typically, the state agency that administers workers' compensation appoints a case manager or adjuster for each claimant. This function may be outsourced or handled within the agency. This person will coordinate the employee's care, authorize treatment, and review the employee's progress. The adjuster might authorize services from the employee's regular primary care provider, or direct them to the carrier's own network of providers.

In addition to responsibilities for being the liaison with the employer and the patient (employee), this individual also can be of help to your practice by providing information, such as the report-of-first injury form or other information about the patient's injury. Nurturing good relationships with case managers and adjusters is essential if you wish to cultivate the workers' compensation business, instead of just survive it.

Seek help. Although workers compensation is administered at the state level, it is an agency of the Department of Labor. If you are having challenges with a payer – or on a particular case – but getting no satisfaction from the state agency, consider reaching out to your regional office of the Department of Labor.

Watch denials carefully. While denial rates for other payers vary from three to seven percent, most practices find that workers' compensation plans initially refuse payment on 30 percent or more of claims. While these denials may be simply ungrounded and accompanied by vague requests for "more information," more often it is a legitimate request. Whether it's a stall tactic or legitimate request, many workers' compensation plans require medical documentation to adjudicate claims.

File claims electronically if possible so you can confirm receipt of transmission. Consider also proactively submitting documentation to support your claims for services instead of awaiting a request for records. This proactive approach may require a bigger investment of time and resources, but a standard workflow — streamlined to minimize the labor required to administer it — helps to ensure that claims are paid in a timely, accurate manner.

Form a cross-trained team. Assigning a cross-disciplinary team to handle workers' compensation helps reduce errors and omissions. This team should include a clerk to handle paperwork for pre-certifications for tests, examinations, and procedures; a scheduler who also handles authorizations and transmits work status notes to employers and claims managers; a billing expert to handle collections tasks and a supervisor who can handle customer relations issues. You may also want to ask one of these team members to sit in when a physician reviews details of a treatment plan with a workers' compensation patient.

Address causation. Ask all providers in the practice to agree on a policy as to whether they will address "causation." Often when lacking a specific event on a specific date, a patient's ailment might be caused by their work or exacerbated by their work but an underlying condition is at play. Because state laws are different about the need to prove causation, practices should research the issue, check with their county and state medical societies and, perhaps, seek legal advice.

Scrutinize forms. A number of state's workers' compensation systems still rely on paper forms. The primary form, the CMS-1500 claim form, should be reviewed carefully to assure that it is completely legible and all fields completed as required. Make sure when printing the form that every entry is aligned with the appropriate data entry space. Because these forms are scanned upon receipt, any entries that are not precisely aligned with the proper fields on the form may be delayed for further processing.

Attend to documentation. Expect that your state's workers' compensation plan will require copies of the physician's or other provider's progress notes with each claim form. Those copies must be legible, complete, and pertain to the codes included on the form. Submitting claims without appropriate documentation will delay payment.

There's no way around it; in most states, handling workers' compensation comes with an administrative burden. You also should expect that it will slow your overall account receivables performance. Assigning staff to focus on workers' compensation billing matters will make the process run smoother. And remember, most patients seeking treatment under this coverage are new to the world of workers' compensation; you will have to help them get through it, too.

Pearl: Relating to Case Managers

Decide how you will accommodate case managers. Your willingness to accommodate their requests will have an impact on whether they steer future business your way. For instance, if a case manager wants to be present for the patient's visit, will you wait for them if they are late? Will you send case managers a copy of all pertinent records immediately after exams and services, or wait for them to request the records? Consider also how will handle the requests and needs of claims adjusters and employers.

Pearl: Beware Silent PPOs

Be watchful for rental networks and silent preferred provider organizations (PPOs) that third party administrators (TPAs) and employers may be using for workers' compensation; these entities may be especially common in states where there is no single payer for workers' compensation. Many self-insured employers outsource the administration of their workers' compensation claims to a TPA which is supposed to coordinate claims investigations, issue claims payments and settlements, and coordinate medical management. When it goes wrong, providers may find themselves being bounced between payers, TPAs, bill review companies and others just to get answers to their payment questions, let alone to get paid. Carefully document every contact and be prepared to approach your state's insurance commissioner, workers' compensation department, medical society and, ultimately, elected officials to get a resolution.

Pearl: Impairment Rating

Determine where in your workflow you will issue an impairment rating. At some point, employers, adjusters and case managers need to know if the patient has met their expected maximum medical improvement (MMI). The impairment rating and MMI are important to determining the patient's potential final payout amount if there is a lifetime loss of use of a part of their body or an inability to work in their current occupation or any occupation.

Will you require a separate appointment for this determination? Will it require pre-payment or be provided as a part of the treatment costs? Accepting a workers' compensation patient is a commitment to handling these details so long as the patient complies with all medical advice throughout their care.

Pearl: Systems Supporting the Complicated Processes

Accuracy and speed of claims processing will suffer if you are not prepared for the unique billing needs of workers' compensation. Set up a separate financial class in the practice management system to monitor the billing and collections for workers' compensation. The system should be prepped to shift the patient back to his or her regular carrier when needed.

These shifts can occur when a patient drops out of workers' compensation or the carrier concludes that the claim is not workplace-related after all. Your practice management system should be able to seamlessly shift those charges to another appropriate fee schedule: the patient's regular insurance plan, Medicaid or your own fee schedule for self-pay patients.

United States