Workers’ Compensation Billing

1. Workers’ Compensation Billing Kimberlee Barriere Maine Workers’ Compensation Board

2. References • Title 39-A § 205(4) • Title 39-A § 206 • Title 39-A § 208 • Title 39-A §209-A • Board Rules and Regulations, Chapter 5 • Title 39-A § 222 • Bureau of Insurance Rules, Chapter 530

3. Title 39-A § 206 • An employee sustaining a personal injury arising out of and in the course of employment or disabled by occupational disease is entitled to reasonable and proper medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids, as needed, paid for by the employer.

4. Jurisdiction • Providers may treat a patient with a Workers’ Compensation claim in a jurisdiction other than Maine. • Payment is pursuant to the jurisdiction’s statutory and regulatory provisions.

5. Pre-authorization • There are no statutory or regulatory provisions requiring pre-authorization for services rendered pursuant to Section 206. • If pre-authorization is obtained, it is NOT a guarantee of payment.

6. Insurance Coverage Verification • http://www.maine.gov/wcb/departments/Coverage/VerifyCoverage.html • The insurer may or may not be the actual claim administrator. • The claim administrator may or may not use a third party to process medical bills. • Bottom Line: Insurer that wrote the policy is ultimately responsible for timely and accurate payment.

7. “Orphan” Medical Bill • Medical bill received by the claim administrator where there is no record of an injury having been reported by the employer. • Bill should not be returned to provider for a failure on the employer’s part. • Thirty day provision allows sufficient time to conduct a claim investigation.

8. M-1 Forms Initial • Due within 5 days of completion of exam • The Board may assess penalties up to $500 per violation on health care providers who fail to comply with the 5-day requirement. • Reimbursable ($30.00 – use CPT 99080) • An insurer or self-insurer may withhold payment of fees for the completion of the initial report to any provider who fails to submit the report on the prescribed form within the time limit provided.

9. M-1 Forms Progress Report (i.e. ongoing Treatment) • Due every 30 days • Not Reimbursable Final • Due within 5 days of termination of treatment • Not Reimbursable

10. M-1 Forms • Other than the section designated for the employee, the remainder of the form is to be completed by the health care provider. • This form must be distributed to the employee, employer and insurer directly.

11. Medical Records • Currently there is no requirement to send the medical records along with a bill for services rendered. • Authorization is not required if the information pertains to treatment of an injury or disease that is claimed to be compensable under the Act. • HIPAA DOES NOT APPLY.

12. Medical Records • A health care provider or facility shall, at the written request of the employer/insurer or the employee, furnish copies of the health care record within 10 business days. • An itemized invoice should accompany the copies. • DO NOT BILL for copies on a HCFA or UB with CPT 99080.

13. Medical Records • In the event that the employer/insurer contends that the medical records and information, pre-existing and subsequent to the workplace injury, …, it may obtain from the employee a limited authorization for focused written medical records only employing Board Form 220.

14. One Stop Shopping • “Sometimes a patient will present to the provider for a workers’ compensation injury and also wish to be seen for a reason unrelated to the employment injury. Providers must be cognizant of the need to keep both encounters separate.” - AAPC

15. Confidentiality • Illness or injuries unrelated to a claimed workers’ compensation injury or illness must never be disclosed to the employer/insurer without authorization! • HIPAA • MSP

16. Statutory Framework – Medical Fee Schedule (MFS) • “to ensure appropriate limitations on the cost of health care services while maintaining broad access for employees to health care providers in the State…”

17. Professional Billing • Individual health care providers must bill insurers directly, i.e. separate from facility fees. • No prescribed billing form. • Bills must specify the date and type of service, the appropriate procedure codes, the conditions treated, and the charges for each service. • Bills should include the date of injury/occurrence.

18. Facility Billing • Facility charges must be billed on a UB-04. • Bills must specify the date and type of service, the appropriate procedure codes, the conditions treated, and the charges for each service. • Bills should include the date of injury/occurrence.

19. Reimbursement • The employer/insurer shall pay the health care providers’ usual and customary charge or the maximum allowable payment under the MFS, whichever is less, within 30 days of receipt (unless the employer/insurer has controverted the underlying claim). • Employer/Insurer not required to send notice of controversy (NOC) to health care provider when controverting the underlying claim.

20. Penalty Payments • When there is no ongoing dispute, if bills are not paid within 30 days after the carrier has received notice of nonpayment by certified mail …, $50 or the amount of the bill due, whichever is less, must be added and paid … for each day over 30 days in which the bills for medical or health care services are not paid. Not more than $1,500 in total may be added pursuant to this subsection.

21. Max Fees - Professional • The MFS for services rendered by individual health care practitioners must reflect the methodology underlying the federal Centers for Medicare and Medicaid Services resource-based relative value scale. • Conversion factors set by Board: • $50 for anesthesia services • $60 for all other

22. Max Fees - Facility • The MFS for services rendered by health care facilities must reflect the methodology underlying the federal Centers for Medicare and Medicaid Services MS-DRGsystem for inpatient services and the APC system for outpatientservices. • Conversion factors set by Board: • Acute Care Hospitals • Critical Access Hospitals • Ambulatory Surgery Centers

23. Notice • There are no statutory or regulatory provisions requiring an explanation of review/explanation of benefits. • If an employer/insurer controverts whether a health care provider’s bill is reasonable and proper under § 206 of the Act, the employer/insurer shall send a copy of the NOC to the health care provider.

24. Notice • Employer/Insurer required to send: • Check for the undisputed amount per the MFS. • Copy of NOC (if applicable).

25. No NOC Required • Employer with no coverage for date of injury/occurrence? • If yes, may return bill to provider • Uncoded bill per Chapter 5, Section 1.06? • If yes, may return bill to provider • Facility charges not on a UB? • If yes, may return bill to provider

26. Reimbursement • Providers must accept payment per the MFS as payment in full. • No deductibles or copays • Balance billing prohibited

27. Balance Due • Appeals/Requests for Reconsideration • No Board jurisdiction • Statute of Limitations (§ 306) • 2 years from the date of Injury • 6 years from the date of the last payment

28. Petition for Payment • If the health care provider disputes any payment received or denied, the health care provider, employee or other interested party shall be entitled to file Board Form 190 or 190(A). • Any health care provider, employee, or other interested party shall be entitled to file Board Form 190 or Form 190(A) for determination of any issue regarding medical services and/or medical billing.

29. Dispute Resolution • Three Tiers: • Claims Resolution Specialists/Troubleshooters) • Mediation • Hearing • Five Regional Offices: • Augusta, Bangor, Caribou, Lewiston, Portland

30. Employee Liability • The injured employee is generally not liable for payment of any health care services for the treatment of a work-related injury or disease. • The health care provider may charge the patient directly only for the treatment of conditions that are unrelated to the compensable injury or disease or if a hearing officer has ordered that the employee is responsible for payment of treatment received from a health care provider of the employee’s choice.

31. Provisional Medical Payments • Payment of benefits due a person under an insured disability plan or insured medical payments plan may not be delayed or refused because that person has filed a workers' compensation claim based on the same personal injury or disease. • Controverted claims (full or partial denials)

32. Provisional Medical Payments • If a patient is awaiting a Board determination on a claim in which the underlying injury has been controverted and the patient is covered under an insured health plan, then the health carrier must determine eligibility and provide benefits according to the terms of the health plan but without regard to any policy exclusion for work-related injury or disease. • Copays and deductibles may apply.

33. 2014 – “A Big Year” • Periodic Update • Rule Language • Medical records • DRGs • Conversion Factors

34. Contact Information Kimberlee K. Barriere Deputy Director Maine Workers' Compensation Board 24 Stone Street, Suite 102 Augusta, ME 04330 Tel: 207-287-7031 Fax: 207-287-3881 Kimberlee.Barriere@maine.gov Email preferred