The workers’ compensation system was created 100 years ago to provide benefits to employees who have suffered a work-related injury while protecting employers from costly litigation related to these on-the-job injuries.The system is supposed to be simple. If you are injured on the job, regardless of whose fault the injury was, your employer must pay for your medical bills and provide disability payments until you are able to return to work. In return, the employee is prohibited from suing the employer, and punitive damages cannot be awarded. In lieu of the court system, a workers’ compensation commission oversees injury-related disputes between employees and employers and resolves these disputes via an arbitration process.
The employer is required to purchase a workers’ compensation insurance policy, and health care providers bill these insurance companies in a manner similar to how they would bill Medicare or private insurance. If an insurance company believes that the claim is illegitimate, it can deny the claim, and the case will likely be heard at the commission, where the arbitrator will decide whether or not the insurance company should pay the medical bill.
The Crisis in Workers’ Compensation
Every state’s regulations are different, but they are all very complex. Standard medical billing software was built for Medicare, Medicaid, and private insurance, and it can’t keep up 50 different sets of workers’ comp regulations. This leaves healthcare providers to deal with the complexity themselves, and they invest a lot of time learning the quirks of the system.
Meanwhile, workers’ compensation insurance carriers are losing money. Policy premiums are down because fewer people are employed during the recession, and expenses are at an all-time high due to rising healthcare costs. The carriers are looking for any way they can to save money, which means they look for any reason they can think of to deny a workers’ comp claim.
The insurance carriers use sophisticated software systems to reject claims automatically. If the physician didn’t follow the billing procedures exactly, the claim will be rejected. If the patient is taking longer to heal than expected, or the treatments cost more than expected, the claim can be rejected.
Each of these cases must be resolved at the workers’ compensation commission, which means the commission is hugely overloaded. In some states, it can take years for a case to be heard. During that time, the physician is not being paid, and worse, the patient is probably not being treated. The patient can’t return to work, which means the employer is out a worker and the employee can’t provide for his or her family.
This hassle is so great that many physicians refuse to treat workers compensation patients at all.
Fire Ant Can Help
At Fire Ant, we think we can help. By utilizing the same type of sophisticated software that the insurance carriers use, we can detect billing mistakes before they are submitted to the carriers. We can respond rapidly to carriers’ questions and inquiries. And we can help the physicians present a more compelling argument at the commission so that they are likely to win the case.
To learn more about our services, or to be notified when our technology is ready for prime time, send us a note.