Orthopedic workers’ comp claims stall for a few predictable reasons: a missing or wrong claim number, treatment without authorization, late or missing medical reports, bills priced off the wrong state fee schedule, and no one following up with the adjuster. Practices get paid faster by collecting the right details at intake and tracking comp claims on their own.
Why is workers’ comp billing different for orthopedic practices?
Workers’ comp is one of the biggest non-traditional payers for most orthopedic groups. Back, shoulder, knee and hand injuries on the job end up in orthopedic offices every day. But comp claims don’t follow the rules of a normal health plan.
Each state runs its own workers’ comp system. Most states set a medical fee schedule that caps what a provider can be paid, and many have their own forms, deadlines and dispute steps. The Workers Compensation Research Institute tracks how prices differ from state to state in its Medical Price Index for Workers’ Compensation. Federal employees are covered by a separate federal program with its own rules.
The insurer is also a different kind of payer. Claims are handled by an adjuster assigned to one injury, and payment depends on whether the carrier has accepted the injury as work-related. A general billing team used to commercial claims can easily treat a comp claim like any other claim, and that is where the delays start.
What are the most common reasons orthopedic comp claims stall?
Most stalled comp claims trace back to one of these:
- Missing or wrong claim number. Without the carrier’s claim number, the bill often can’t be matched to the injury.
- Injury not yet accepted. If the carrier is still investigating, bills can sit or be denied until the claim is accepted.
- No authorization. MRIs, injections, surgery and therapy frequently need approval from the adjuster before they are done.
- Missing medical reports. Many states require specific reports with the bill, such as an initial report and progress reports. A bill without them may be treated as incomplete.
- Wrong fee schedule. A bill priced from your commercial fee schedule instead of the state’s comp fee schedule leads to reductions and confusion.
- Billed to the wrong payer. Sending a work injury to the patient’s health plan usually brings a denial and lost time.
- No follow-up. Comp claims often need a phone call to the adjuster. If no one owns that call, the claim sits.
Each of these can be fixed with better process. None of them require the patient’s help after the first visit.
What information should you collect at the first visit?
Most comp delays start at the front desk. Build a short comp intake checklist and use it for every work injury:
- Employer name, address and contact person.
- Date of injury and a short description of how it happened.
- Workers’ comp carrier name and the claim number, if one has been assigned.
- Adjuster or case manager name, phone and email.
- Any authorization already given, and what it covers.
- Whether the patient has an attorney on the claim.
If there is no claim number yet, flag the account and follow up with the employer or carrier until you have one. Don’t let the visit go out as a regular health insurance claim.
Rules vary by state and carrier, but orthopedic practices should expect to request approval for most care beyond the first evaluation. That includes advanced imaging, injections, surgery, durable medical equipment and physical therapy.
Keep a record of every request and every approval, with the date, the adjuster’s name and exactly what was approved. When the plan of care changes, request a new approval before the service. A surgery done without approval can be very hard to get paid, even if it was clearly needed.
Which reports do comp carriers expect?
Most carriers expect medical reports that explain the injury, the treatment plan and the patient’s work status. Some states use required forms. New York, for example, uses the C-4 doctor’s initial report, and California uses the PR-2 progress report from the primary treating physician. Other states have their own versions.
Late or missing reports are one of the easiest problems to fix. Build report deadlines into your scheduling so each progress note goes out with or before the bill, and keep a copy of what was sent and when.
How should you track and follow up on comp AR?
Comp claims take longer to pay than most commercial claims, so they need their own report. If comp AR is mixed in with the rest of your AR, a few slow comp claims can hide inside a healthy overall number, or make a good month look bad.
Track comp AR separately and set a follow-up schedule. A practical approach:
- Review every comp claim with no payment after 30 days.
- Call or email the adjuster, note the answer and set the next follow-up date.
- Send any missing reports or authorizations the same day.
- If a bill is reduced or denied, check it against the state fee schedule and use the state’s dispute process when the reduction is wrong.
When a patient also has Medicare, comp settlements bring their own rules. CMS explains how future medical costs are handled in Workers’ Compensation Medicare Set Aside Arrangements.
What results are possible when comp is billed on its own track?
Orthopedic Specialists of Massachusetts came to Medical Healthcare Solutions, Inc. (MHS) with AR running above benchmark on both its standard and workers’ comp claims. MHS set up separate workers’ comp billing protocols for the practice. Workers’ comp days in AR fell from 58 to 46. Standard days in AR dropped from 36 to 29, net collection rose from 92% to 97%, and the practice added about $113,000 a month in collections. You can read the details in the orthopedic practice case study.
Comp denials follow the same basic pattern as other denials: find the root cause, fix it at the source and appeal what can be won. Our posts on denial management strategies for orthopedic billing and our denial management services go deeper on that process.
When should you get outside help with workers’ comp billing?
Consider outside help if comp claims regularly sit past 60 days, if your team doesn’t know which state forms and fee schedules apply, or if comp is growing as a share of your payer mix. MHS, based in Andover, Massachusetts, bills for orthopedic practices and surgery centers, and our orthopedic medical billing services include workers’ comp and auto claims.
Frequently asked questions
Why do orthopedic workers’ comp claims take so long to pay?
Comp claims depend on the carrier accepting the injury, the right claim number, prior authorization, required medical reports and the state fee schedule. A gap in any of these can hold up payment, and many claims also need direct follow-up with the adjuster.
Do orthopedic comp patients need prior authorization?
Often, yes. Rules vary by state and carrier, but imaging, injections, surgery, equipment and therapy frequently need approval from the adjuster before the service.
What should we collect when a work injury patient checks in?
Employer details, date and description of the injury, carrier name, claim number, adjuster contact information, any existing authorization, and whether the patient has an attorney.
Should workers’ comp AR be tracked separately?
Yes. Comp claims take longer to pay than most commercial claims, so tracking them on their own report shows where they are stuck and keeps them from skewing your overall AR.
Are comp claims slowing down your cash flow? Get Pricing & Analysis and MHS will review your workers’ comp AR alongside the rest of your claims and show you where payments are getting stuck.
