The Right Moves

Six steps to avoid workers’ compensation claim denials.

By Connie Ziccarelli

The center of any workers’ compensation case management process should be proactive and efficient communication. Patients who are injured on the job automatically assume someone else will pay their claims, so it is the physical therapist’s responsibility to document and communicate effectively with the adjustor and case manager to ensure no hiccups disrupt the payment process.

Denials can be frustrating. In the worst case scenarios, which are typically caused by poor documentation that can lead to the patient footing the bill, adjustors and case managers become irked with the lack of efficiency, and employers lose trust in a physical therapist’s (PT) services. A PT may initially think that one denied claim is no big deal, but soon realizes that customers are three times more likely to share negative experiences with others—and it takes 12 positive experiences to make up for one negative one. To keep all parties happy and ensure the claims process runs speedily and smoothly, there are six steps you can put in place to help avoid claim denials:

Step 1: Have a full understanding of the injury and the job duties to which the patient needs to return. The moment a worker’s compensation patient sets foot in your practice, contact the employer and obtain a copy of the injury report, which will give you a full understanding of how the injury occurred and its timeline. In addition, it allows you to appreciate the patient’s job tasks to which he or she needs to return. If possible, perform a Job Demands Analysis (JDA). With permission, visit the worker’s job site to learn about each task he or she needs to complete in a given day. Take special notice of the frequency, weight requirements, and movement patterns each task requires. Gathering all this information will allow you to set realistic and specific timelines and ensure the plan of care reflects return-to-work goals.

Step 2: Determine potential services needed throughout the course of treatment. Adjustors and case managers do not like surprises. They want to be actively involved in all aspects of the injured worker’s care and offer their insight. Therefore, hold an open discussion with them at the beginning of a patient’s treatment to convey any services you feel may complement the plan of care. This dialogue may include a job site visit or a potential work-hardening/work-conditioning program. Some of the services you may not even end up utilizing, but it is better to have an open discussion upfront rather than beg for or be denied services later.

Step 3: Clearly state goals and focus on function/return-to-work activities. When documenting for a worker’s compensation case, be sure that all goals focus on returning the patient to work. To master the art of functional goal writing, goals must be patient specific, objective and measureable, focus on function, and include the anticipated timeframe in addition to being work-specific. Throughout the course of therapy, your documentation and goals should never mention anything regarding leisure activity.

Step 4: Identify the proper diagnosis codes relating to injury on the insurance claim. One of the simplest mistakes that leads to a rejected claim is reporting diagnosis codes that do not relate to the injury. If you recall step one, it was important to gather as much information about the injury as possible, which will help you in step four. Prior to submitting a claim to the insurance company, perform an internal audit to ensure that your diagnosis code accurately reflects the injury.

Step 5: Attach therapy notes to submit with the claim. When submitting a claim, attach any accompanying treatment notes or progress reports. This task aids the adjustor or case manager in reviewing the claim. They have all the information readily available to them at their fingertips and do not spend countless hours playing phone tag to request further documentation. This should be considered a continuation of the discussions that you set up in step two. Remember, the key to forming good relationships with adjustors and case managers is proactive communication.

Step 6: Create an efficient Accounts Receivable Management process. To ensure all claims are processing correctly, follow up after two weeks of submission. A simple phone call to the payer to determine if the claim was received and if there are any questions regarding the claim form or documentation will suffice. Continue to follow up every two to three weeks until the claim is paid in full. Should the dreaded denial find its way to your mailbox, do not delay. Immediately call the adjustor or case manager to determine the reason for the denial and their policy for written appeals. Nine times out of ten, this conversation will overturn the denial. Should you need to submit a written appeal, include all medical records that support your letter and schedule follow-ups in your calendar. Also, keep the injured worker/patient involved and informed every step of the way. The patient can actually be your strongest ally and asset in your accounts receivable management team as they may have a stronger pull in overturning the denial.

Proactive and effective communication is the key to reducing denials and receiving speedy payment. As the therapy provider, it is your duty to (1) have a full understanding of the patient’s injury, (2) determine potential services needed throughout the course of rehabilitation, (3) focus on return-to-work and function in goals, (4) identify the correct diagnosis codes relating to the injury, (5) attach accompanying therapy notes to claim submissions, and (6) create an efficient accounts receivable management process. Following these six steps will allow you to keep all individuals involved in the case management process happy and ensure that there are no hiccups in claims processing and payment. Because you have taken the extra time to complete these steps, you will also be recognized by many stakeholders—patients, employers, case managers, adjustors, physicians, safety directors—as a standout destination center specializing in the “industrial athlete.”

Connie Ziccarelli is chairperson of the PPS Administrator’s Council and co-founder, principal, and chief operating officer of Rehab Management Solutions in Sturtevant, Wisconsin. She can be reached at cziccarelli@rehabmgtsolutions.com.