WC Claims
What information do we verify with the adjuster when we call prior to the patient's appointment?
We verify the claim is open and active, claim #, claim address, DOI, phone/fax, and that we have the correct adjuster as well as if there is a nurse case manager and for what body part, and if they are willing to authorize any visits (eval +), we also want to know who the authorization goes through and how to contact them.
What is an SB811?
SB811 is a letter to inform the patient that they are Self-Pay and that an estimate is being provided for services.
The "SB811" is for patients with no insurance while the "SB811 OON" is for patients who may want an estimate who have insurance but a high deductible and may be financially responsible for their cost of care
If a patient has no medical coverage on their MV insurance and give us a declaration page or no Med-Pay letter, can we bill their health insurance?
Yes! This is the only time we can bill their personal health insurance if they have been involved in an MVA
For the Default Authorization Line do we need to fill in the entire line for all insurances regardless of if it is No Auth Required, QMB or an actual Authorization?
Yes, the Auth #, Start and End Dates as well as the counters must be filled in.
what do you say when you answer the phone in the clinic?
Good (Morning/Afternoon), ___Hospital Name__, this is __YourName__, How can I help you?
What form do we need from an adjuster to bill through a patient's health insurance?
If a patient is denied though WC, we need a Form 43 from the adjuster to send to the health insurance with the clinical notes when submitting for authorization to show the patient was denied.
If the patient has health insurance and decides to be Self-Pay are they eligible to receive the discount?
No, We need to remove the Self-Pay discount if the patient has insurance, but choosed not to utilize it.
What is Med-Pay?
Med-Pay is an additional coverage option for auto insurance policies in most states. In the event of a car accident, this coverage can help pay for medical expenses for the policy holder
What needs to be filled in on the referral when entering an authorization?
Auth Status
Communications
Start / Expiration date and counters in Authorization Tab
Auth Grid
Auth #, From / To Date and counters in Default Auth line
When should we have a score for a patient on a functional tool? (Quick Dash, LEFS, NDI, MDQ, PFIQ, LLIS etc)
When ever the patient is evaluated or a new Progress Note is done at the very least. We need these scores to obtain authorizations from the insurances. Best practice is at every visit.
If a patient is WC and does not have their claim information can we bill their health insurance?
NO! We set up the guarantor for WC as this will allow it to be billed to the employer and not to the patient in this case. The patient would not necessarily be responsible to pay for the medical bills if it was a WC claim. Only after the claim is denied would the patient be responsible to either provide their personal health insurance or be self-pay
What documents need to be signed and scanned for Self-Pay at each visit?
SB811 Letter and the estimate with charges.
Always best to have a signature on the page where the charges are and a signature on the letter then they all need to be scanned into the MM
How are visits decided for a Med-Pay amount
Central office will divide the amount by an average cost per visit. We should have a patient's health insurance pulled in as a secondary coverage for when the amount has been exhausted so it can roll to that policy. We should also be submitting for that insurance's authorizations as the patient is seen as a back up
If a patient is seen for their last visit and needs a re-auth what do we set the counters in the Authorization Tab to?
500 - but only after the patient has been checked in for their last approved visit or the last visit the patient will be seen prior to the end date running out. The therapist needs to do a PN at this visit in order for the CPSR or PSR to submit for more visits.
Do we need a Carelon Form to be filled out by the therapist and scanned in for re-auths as well as for evals?
YES! There is a section on there for initial evaluations and a separate section for re-auths that help the Central team facilitate getting those visits authorized from Carelon. If this is not filled in and scanned into the chart, the answers are not always available to us when obtaining auth.
What happens if a patient is denied by WC?
The site will receive notification from the home office in regards to the denial. The site would communicate to the patient they were denied coverage through workers compensation and to reach out to their adjustor or employer. If the patient wants to continue, they will sign a self-pay waiver or provide personal insurance for medical expenses.
How do we remove the Self-Pay discount from an estimate?
You can do it 2 ways:
You can click the discounted total in the "TOTAL" section after adding in all CPT codes and the discount percentage box pops up to the left of the box, you can put 0 in the box and hit enter
Or you can 0 out the discount box with each CPT code you add.
If a patient has not opened a claim with their MV insurance and has medical coverage and wants to bill through their health insurance, can we? Why?
NO, If the patient has medical coverage we need to exhaust that prior to billing their health insurance or the health insurance can deny the claim stating to bill the MV policy
In the Default Authorization when do we add the "No Auth Required" 1V for the eval date and for which insurance? How do we update the authorization tab?
We add this to a Medicaid authorization for a set number of visits for an initial evaluaton as the 1st eval of the year. We add the 1V to the total number of visits that Medicaid authorizes.
EX. Medicaid auth for 12 V + 1 V eval = 13 V in the Authorization Tab counters
What are the site responsible insurances for clinics with a CPSR?
Medicaid
Wellcare
Optumcare (UHC, Anthem, CTCare APN plans)
UHC MGD
Unicare
Cigna - Speech
Capital Blue
VA/Tricare Active Duty
Tricare East
Anthem BCBS MTN prefix plans
WC/MVA to obtain and verify info - auth for eval
What information do we need from the patient for a WC claim?
WC insurance Carrier
Claims Address
DOI
Claim Number
Adjuster's Name, Phone and Fax
Employer, Phone and Address
If the patient is marked for Self-Pay because of MVA or WC are they eligible for the discount?
No! The patient is not eligible for the self-pay discount as a MVA or WC patient. We need to remove the Self-Pay discount from the estimate.
If a patient is in the back seat as a passenger in a car and is hurt in an MVA can we bill their health insurance? Why?
NO! We need a Med-Pay or declaration page from their personal car insurance letting us know they have no medical coverage to bill their health insurance. If they have no insurance they would be a self-pay and would have to submit their bills to the person at fault to pay. It does not matter where in the car the patient was (driver/passenger) the Med-Pay must be through their own vehicle's insurance
How do we transcribe an order?
Transcribe order from toolbar
add the provider
"add order" AMB ___(Therapy (PT/OT)/Speech)
choose department
initial evaluation/neuro condition
add in the DX association (add dx, check box and accept)
sign order
What is an insurance referral or PCP referral?
An insurance referral is to be submitted to your insurance directly by the PCP you have on file with your plan for approval of therapy services, even if they are not the provider referring you to therapy. Once approved by your insurance plan, the insurance referral will include a number of approved visits, a date range to use the approved visits, and an approval number which will be submitted on your claim for services rendered to your insurance plan.
It is the patient's responsibility to ensure this approval is in place prior to services being rendered to avoid denials.