RELATIONSHIPS ARE IMPORTANT: The workers compensation industry is very small, creating an environment where relationships are essential. The medical community fosters a similar atmosphere. The communication necessary for bill negotiations needs to be elevated to a clinical dialogue. This instills value and trust between the treating providers and workers compensation professionals. Treating people with respect builds rapport and establishes trust throughout the entire process. Building these trusting relationships allows providers the ability to flex, compromise, and provide savings where they may not have before. When all parties feel they are winning, negotiations are possible: win, and the bill is put to rest.

MEDICAL BILLING IS AN ART: Specific training exists for medical providers to enhance coding and ensure comprehensive bills that will cover their costs. Networks make drastic cuts as general health insurance has agreements and contracts for leverage. When bills are coded for services rendered, the medical coder does not differentiate between workers compensation and personal health; therefore, all bills are coded the same. For medical bills to cover the cost of medical providers and facilities expenses, unique manners are used to code for procedures for networks’ contractual agreements to net a reasonable outcome.

CODING CAN HAVE ERRORS: Having nurses and certified coders review larger medical bills can be helpful since they understand the unique nature of this process. This can be the payment difference for a hernia repair coded for one mesh piece versus the entire box. A nurse may differentiate between what could have been done and what could not have been done, which can be a very small difference between procedural codes. This is a unique skill set for one to possess.

FEE SCHEDULING: Fee scheduling is how the workers compensation system has responded to the networking of providers and network decreases found in the personal health side of insurance. All but seven states participate in this programming for workers’ compensation. A lot can vary with fee schedules. These variances depend on state jurisdiction, medical treatment or procedure, facility, etc. Fee schedules provide a baseline number of what should be paid, and if everything has been applied appropriately, the bill will result in a reasonable amount for the service.

THE BILL REVIEW ‘GAME’:  There appears to be a ‘game’ associated with medical bill review in the workers compensation world. Bills will move through an algorithm, and payment will be made to a facility or provider in good faith. The facility or provider will then have to appeal the amount paid as a reconsideration for review, justifying why further payment should be rendered. This cycle can occur multiple times per bill, causing increased work for adjusters and health care professionals. Having humans negotiate these larger bills reduces the number of reconsiderations and the ‘game’ played between the standard medical bill review process, adjusters, and medical bill providers. Lessening the ‘game’ can increase the reputation of companies and medical facilities, especially in remote areas where limited treatment is available.