News & Current Issues
Old TEXAS WORK COMP news:
Texas Workers Compensation System Changes 2006
SOAH Stoploss claims get panel decision January 2007
Texas Workers Compensation System Changes 2006
SOAH Stoploss claims get panel decision January 2007
Old LOUISIANA WORK COMP news:
Louisiana Work Comp Update 2006
Coventry buys Concentra, February 2007
Louisiana Work Comp Update 2006
Coventry buys Concentra, February 2007
Louisiana Work Comp Advisory Group (WCAG) reviews the proposed bill for PPO legislation. The WCAG hopes to close the gap with providers
being able to use other agreements on a work comp claim reimbursement. The group has had a number of meetings with the Department of
Labor and hopes to finalize their bill draft suggestions soon.
As many of you know, calculating reimbursement on a work comp claim is sometimes impossible not knowing who is contracted with who,
who is going to use the contract, who is using an expired contract, or who is actually going to pay by the DOL fee schedule. Working directly
with the DOL, the WCAG should be able to prevent these types of issues which would allow hosptials to process correct adjustments at an
earlier timeframe and better managed cash flow for that financial class.
For information on how to be a part of the WCAG, please contact Angie Box at (817) 200-2820, ext. 206
being able to use other agreements on a work comp claim reimbursement. The group has had a number of meetings with the Department of
Labor and hopes to finalize their bill draft suggestions soon.
As many of you know, calculating reimbursement on a work comp claim is sometimes impossible not knowing who is contracted with who,
who is going to use the contract, who is using an expired contract, or who is actually going to pay by the DOL fee schedule. Working directly
with the DOL, the WCAG should be able to prevent these types of issues which would allow hosptials to process correct adjustments at an
earlier timeframe and better managed cash flow for that financial class.
For information on how to be a part of the WCAG, please contact Angie Box at (817) 200-2820, ext. 206
The Work Comp Advisory Group works with the Department of Labor on the Omnibus Bill regarding
PPO legislation - February 2007
PPO legislation - February 2007
Effective March 1, 2008, TDI issued changes to the workers’ compensation fee
Medical Dispute Resolution, etc. remained unchanged.
reimbursement for trauma diagnosis claims, perdiems with carveouts (including but
not limited to cost+10% on implantables), line item reimbursement based on
Medicare for outpatient radiology, pathology and lab. All other charge types not
mentioned were paid at a “fair and reasonable” calculation as determined by the
payors.
The new schedule for inpatient claims is one of the two options:
1) 108%-of-Medicare AND implants paid at cost+10%; however, this declaration must
be made AT BILLING
2) 143%-of-Medicare with no additional for implants. Should declaration not be made
at billing, reimbursement will be at this rate (automatically)
The new schedule for outpatient claims is one of the two options:
1) 130%-of-Medicare with implants paid at cost+10%; however, this declaration must
be made AT BILLING
2) 200%-of-Medicare with no additional for implants. Should declaration not be made
at billing, reimbursement will be at this rate (automatically)
Once an appeal is denied by the payor, there is only a 1 year window to file an appeal
to Texas Department of Insurance (Medical Dispute Resolution). With the new
schedule being easier to calculate than the undefined “fair and reasonable”, it is
imperative hospitals begin the process of auditing the past year’s paid out work comp
claims to ensure they have received every dollar possible.
All claims pertaining the old fee schedule (February 29th and prior) should be
reviewed. NOTE: You MUST file an appeal to the carrier and be able to provide
ample time for the carrier to reply BEFORE filing an MDR with TDI. You have a 1 year
deadline to file for an MDR! This makes this project extremely time-sensitive.
Medical Dispute Resolution, etc. remained unchanged.
reimbursement for trauma diagnosis claims, perdiems with carveouts (including but
not limited to cost+10% on implantables), line item reimbursement based on
Medicare for outpatient radiology, pathology and lab. All other charge types not
mentioned were paid at a “fair and reasonable” calculation as determined by the
payors.
The new schedule for inpatient claims is one of the two options:
1) 108%-of-Medicare AND implants paid at cost+10%; however, this declaration must
be made AT BILLING
2) 143%-of-Medicare with no additional for implants. Should declaration not be made
at billing, reimbursement will be at this rate (automatically)
The new schedule for outpatient claims is one of the two options:
1) 130%-of-Medicare with implants paid at cost+10%; however, this declaration must
be made AT BILLING
2) 200%-of-Medicare with no additional for implants. Should declaration not be made
at billing, reimbursement will be at this rate (automatically)
Once an appeal is denied by the payor, there is only a 1 year window to file an appeal
to Texas Department of Insurance (Medical Dispute Resolution). With the new
schedule being easier to calculate than the undefined “fair and reasonable”, it is
imperative hospitals begin the process of auditing the past year’s paid out work comp
claims to ensure they have received every dollar possible.
All claims pertaining the old fee schedule (February 29th and prior) should be
reviewed. NOTE: You MUST file an appeal to the carrier and be able to provide
ample time for the carrier to reply BEFORE filing an MDR with TDI. You have a 1 year
deadline to file for an MDR! This makes this project extremely time-sensitive.
TEXAS WORKERS COMP...a memo from Angie Box
TEXAS WORKERS COMP UPDATE
Representatives from HRA are in the process of scheduling a meeting with TDI Office of Workers
Compensation to discuss issues including, but not limited to, medical dispute resolution, timely filing
period, criteria for appeals, and calculating Medicare reimbursement. These are just some of the the
meeting with TDI having a clear idea of how much training needs to occur with payors in Texas.
Should you have any issues you would like added to our agenda, please email
Compensation to discuss issues including, but not limited to, medical dispute resolution, timely filing
period, criteria for appeals, and calculating Medicare reimbursement. These are just some of the the
meeting with TDI having a clear idea of how much training needs to occur with payors in Texas.
Should you have any issues you would like added to our agenda, please email
LOUISIANA WORKERS COMP
outpatient claims that are to be reimbursed at 90% of charges. Accusations of hospital over-charging, globaling charges, and
declaring certain charges as non-covered is allowing payors throughout the state to pay at what they deem to be a UCR
reimbursement rate that most say is based on charges. HRA has not been able to find any correlation between UCR databases,
Medicare reimbursement, historical trends or PPO contracts to justify the sometimes incredibly low reimbursement rates. With some
of the payors, the "fair and reasonable" rate differs from patient to patient that have the exact same billed charges!
Some hospitals in the State are involved in suits against the payors and are actively filing 1008's with the Office of Workers
Compensation. HRA will continue auditing payments on claims and keep you updated.
declaring certain charges as non-covered is allowing payors throughout the state to pay at what they deem to be a UCR
reimbursement rate that most say is based on charges. HRA has not been able to find any correlation between UCR databases,
Medicare reimbursement, historical trends or PPO contracts to justify the sometimes incredibly low reimbursement rates. With some
of the payors, the "fair and reasonable" rate differs from patient to patient that have the exact same billed charges!
Some hospitals in the State are involved in suits against the payors and are actively filing 1008's with the Office of Workers
Compensation. HRA will continue auditing payments on claims and keep you updated.
HRA is currently finding a significant amount of underpayments in the following states: Arkansas Georgia Louisiana Mississippi Oklahoma Texas South Carolina Washington If you having concerns about the level of reimbursement you are receiving on a workers comp claims, please contact our office at 800-710-2825. |
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