Occupational Medicine billing and accounts receivable

Occupational medicine barely touches health insurance. It bills employers, workers' compensation carriers and state fee schedules — three payers whose rules have nothing to do with commercial billing.

Where the money leaks in occupational medicine

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Workers' compensation claims worked as commercial claims and denied on the wrong basis
• Employer-billed services sent to the health plan, or the reverse
• State workers' compensation fee schedule not applied, so payment is short and nobody chased it
• Authorization from the claims adjuster absent before treatment continued
• Return-to-work and disability paperwork billed without the payer's required forms

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working occupational medicine, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “State workers' compensation fee schedule not applied, so payment is short and nobody chased it”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Authorization from the claims adjuster absent before treatment continued”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a occupational medicine AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions