Workers Comp Claims Authorized then Denied

[Guest guest]

We have been having increasing difficulty getting paid for workers

comp. claims. Recently we were seeing a gentleman for shoulder

problems due to a recent WC injury. In the course of treatment he

requested that we see him for his back which he claimed was the result

of a work related fall in 1995. We contacted the WC carrier by phone

and they authorized treatment of the back condition in addition to the

shoulder. A month later we submitted the bill with notes as

requested. The WC rep called and said they would not cover any

treatment for his back and to bill it to his primary insurance carrier

instead. This is not possible since his primary insurance carrier

requires pre-authorization.

The patient became irate when we suggested that he would be

responsible for the balance of what his insurance refused to cover.

Of course in his mind, his little plastic card covers all and if the

company does not pay us, oh well then it's our problem.

Any suggestions on how to avoid these situations with WC carriers?

Ideas on how to take a more defensive or protected position? WC

representatives give authorization for treatment, then either cal and

renege or refuse to pay the bill. After the fact we can go after the

patient for the balance on his account, but in a small town it creates

bad blood and bad buzz. The patient can go after the WC carrier in

court but that takes years and in our experience is not often

successful. It would be much nicer if we could avoid the issue in the

first place.

Bruce D. Duncan. MSW

Office Manager

Thunder Bay Therapy & Sports Medicine

[Guest guest]

When we get W/C authorization we write down the time, the date and the name

of the person who authorized the treatment. We then send a confirmation

fax. We are in California.

Workers Comp Claims Authorized then Denied

We have been having increasing difficulty getting paid for workers

comp. claims. Recently we were seeing a gentleman for shoulder

problems due to a recent WC injury. In the course of treatment he

requested that we see him for his back which he claimed was the result

of a work related fall in 1995. We contacted the WC carrier by phone

and they authorized treatment of the back condition in addition to the

shoulder. A month later we submitted the bill with notes as

requested. The WC rep called and said they would not cover any

treatment for his back and to bill it to his primary insurance carrier

instead. This is not possible since his primary insurance carrier

requires pre-authorization.

The patient became irate when we suggested that he would be

responsible for the balance of what his insurance refused to cover.

Of course in his mind, his little plastic card covers all and if the

company does not pay us, oh well then it's our problem.

Any suggestions on how to avoid these situations with WC carriers?

Ideas on how to take a more defensive or protected position? WC

representatives give authorization for treatment, then either cal and

renege or refuse to pay the bill. After the fact we can go after the

patient for the balance on his account, but in a small town it creates

bad blood and bad buzz. The patient can go after the WC carrier in

court but that takes years and in our experience is not often

successful. It would be much nicer if we could avoid the issue in the

first place.

Bruce D. Duncan. MSW

Office Manager

Thunder Bay Therapy & Sports Medicine

[Guest guest]

We have had a few claims denied recently despite the fact that our

insurance verifier had received " verbal approval " including a claim

number. This past month, we modified our procedure to require a paper

trail where we will schedule the patient, but will cancel the

appointment if the company or case worker does not fax us " written "

confirmation of the approval, including the name of the person

authorizing the treatment, their position, case number, number of

initial visits authorized, and contact information. The received fax

will have the fax number, date, and time from where the authorization

came from.

It is interesting that some companies will balk at this request. Talk

about red flags.

Bob Lueke, PT

>

> We have been having increasing difficulty getting paid for workers

> comp. claims. Recently we were seeing a gentleman for shoulder

> problems due to a recent WC injury. In the course of treatment he

> requested that we see him for his back which he claimed was the result

> of a work related fall in 1995. We contacted the WC carrier by phone

> and they authorized treatment of the back condition in addition to the

> shoulder. A month later we submitted the bill with notes as

> requested. The WC rep called and said they would not cover any

> treatment for his back and to bill it to his primary insurance carrier

> instead. This is not possible since his primary insurance carrier

> requires pre-authorization.

>

> The patient became irate when we suggested that he would be

> responsible for the balance of what his insurance refused to cover.

> Of course in his mind, his little plastic card covers all and if the

> company does not pay us, oh well then it's our problem.

>

> Any suggestions on how to avoid these situations with WC carriers?

> Ideas on how to take a more defensive or protected position? WC

> representatives give authorization for treatment, then either cal and

> renege or refuse to pay the bill. After the fact we can go after the

> patient for the balance on his account, but in a small town it creates

> bad blood and bad buzz. The patient can go after the WC carrier in

> court but that takes years and in our experience is not often

> successful. It would be much nicer if we could avoid the issue in the

> first place.

>

> Bruce D. Duncan. MSW

> Office Manager

> Thunder Bay Therapy & Sports Medicine

>

[Guest guest]

Thanks Bob;

The verbal approval is what we have always done. We have a form where

we gather the name of the person giving approval, date, case number

and any other information needed to submit the claim. Even with this,

we are running into more problems where the WC carrier just says

" tough - we won't pay it " .

Sounds like we need to take it to the next level of a written faxed

verification like you have implemented. If the company balks at that,

maybe we should treat that the same as a denial? Thanks for the thought.

Bruce Duncan, MSW

>

> We have had a few claims denied recently despite the fact that our

> insurance verifier had received " verbal approval " including a claim

> number. This past month, we modified our procedure to require a paper

> trail where we will schedule the patient, but will cancel the

> appointment if the company or case worker does not fax us " written "

> confirmation of the approval, including the name of the person

> authorizing the treatment, their position, case number, number of

> initial visits authorized, and contact information. The received fax

> will have the fax number, date, and time from where the authorization

> came from.

>

> It is interesting that some companies will balk at this request. Talk

> about red flags.

>

> Bob Lueke, PT

>

> >

> > We have been having increasing difficulty getting paid for workers

> > comp. claims. Recently we were seeing a gentleman for shoulder

> > problems due to a recent WC injury. In the course of treatment he

> > requested that we see him for his back which he claimed was the result

> > of a work related fall in 1995. We contacted the WC carrier by phone

> > and they authorized treatment of the back condition in addition to the

> > shoulder. A month later we submitted the bill with notes as

> > requested. The WC rep called and said they would not cover any

> > treatment for his back and to bill it to his primary insurance carrier

> > instead. This is not possible since his primary insurance carrier

> > requires pre-authorization.

> >

> > The patient became irate when we suggested that he would be

> > responsible for the balance of what his insurance refused to cover.

> > Of course in his mind, his little plastic card covers all and if the

> > company does not pay us, oh well then it's our problem.

> >

> > Any suggestions on how to avoid these situations with WC carriers?

> > Ideas on how to take a more defensive or protected position? WC

> > representatives give authorization for treatment, then either cal and

> > renege or refuse to pay the bill. After the fact we can go after the

> > patient for the balance on his account, but in a small town it creates

> > bad blood and bad buzz. The patient can go after the WC carrier in

> > court but that takes years and in our experience is not often

> > successful. It would be much nicer if we could avoid the issue in the

> > first place.

> >

> > Bruce D. Duncan. MSW

> > Office Manager

> > Thunder Bay Therapy & Sports Medicine

> >

>

[Guest guest]

In Mississippi we have a? workman's comp commission that has a complaint form

that can be filled out.? We submit this to the commission and we have gotten

paid on these cases.? You might want to try that.? I believe the website for you

is www.michigan.gov/dleg?to find your workmans comp commission

Oh, by the way, please include where you are next time.?I had to go googling to

find your location.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: Workers Comp Claims Authorized then Denied

Thanks Bob;

The verbal approval is what we have always done. We have a form where

we gather the name of the person giving approval, date, case number

and any other information needed to submit the claim. Even with this,

we are running into more problems where the WC carrier just says

" tough - we won't pay it " .

Sounds like we need to take it to the next level of a written faxed

verification like you have implemented. If the company balks at that,

maybe we should treat that the same as a denial? Thanks for the thought.

Bruce Duncan, MSW

>

> We have had a few claims denied recently despite the fact that our

> insurance verifier had received " verbal approval " including a claim

> number. This past month, we modified our procedure to require a paper

> trail where we will schedule the patient, but will cancel the

> appointment if the company or case worker does not fax us " written "

> confirmation of the approval, including the name of the person

> authorizing the treatment, their position, case number, number of

> initial visits authorized, and contact information. The received fax

> will have the fax number, date, and time from where the authorization

> came from.

>

> It is interesting that some companies will balk at this request. Talk

> about red flags.

>

> Bob Lueke, PT

>

> >

> > We have been having increasing difficulty getting paid for workers

> > comp. claims. Recently we were seeing a gentleman for shoulder

> > problems due to a recent WC injury. In the course of treatment he

> > requested that we see him for his back which he claimed was the result

> > of a work related fall in 1995. We contacted the WC carrier by phone

> > and they authorized treatment of the back condition in addition to the

> > shoulder. A month later we submitted the bill with notes as

> > requested. The WC rep called and said they would not cover any

> > treatment for his back and to bill it to his primary insurance carrier

> > instead. This is not possible since his primary insurance carrier

> > requires pre-authorization.

> >

> > The patient became irate when we suggested that he would be

> > responsible for the balance of what his insurance refused to cover.

> > Of course in his mind, his little plastic card covers all and if the

> > company does not pay us, oh well then it's our problem.

> >

> > Any suggestions on how to avoid these situations with WC carriers?

> > Ideas on how to take a more defensive or protected position? WC

> > representatives give authorization for treatment, then either cal and

> > renege or refuse to pay the bill. After the fact we can go after the

> > patient for the balance on his account, but in a small town it creates

> > bad blood and bad buzz. The patient can go after the WC carrier in

> > court but that takes years and in our experience is not often

> > successful. It would be much nicer if we could avoid the issue in the

> > first place.

> >

> > Bruce D. Duncan. MSW

> > Office Manager

> > Thunder Bay Therapy & Sports Medicine

> >

>