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Processing workers’ comp claims shouldn’t be a pain in the neck


Workers’ compensation cases can be particularly troublesome because insurers require extensive documentation.

Processing workers’ comp claims shouldn’t be a pain in the neck

Although medical practices that focus solely on workers’ compensation claims do exist, even more medical providers accept workers’ comp cases along with regular patient appointments.

Accepting different types of insurance such as workers’ comp can help practices gain top-line revenue — as long as billers submit claims data in a way the insurer will readily accept. Studies vary, but some medical practices have clean claims ratios as low as 65%, which means 35% of claims need to be reworked, efforts that delay payment by days or weeks and cause additional work for already overburdened back-office staff. Those delays cost practices an estimated $20 billion a year in delayed or lost reimbursement.

Workers’ compensation cases can be particularly troublesome because insurers require documentation of the work-related illness or injury and progress toward recovery, increasing the onus on practices. State regulations about claims filing differ, but electronic claims are generally accepted and paid more quickly than paper ones. However, unwieldy methods of attaching files or reworking claims create problems for medical practice staff who often resort to snail mail or fax machines, delaying reimbursement further.

Filing workers’ comp claims shouldn’t be a pain in the neck, which is why medical staff need solutions that make the workers’ compensation claims process as easy as possible.

Electronic much better than paper for quick payment

When it comes to filing workers’ compensation claims, electronic is definitely the way to go for providers who want to be reimbursed for their time and effort as soon as possible. However, state regulations vary widely on how these claims should be filed and how soon they will be paid. These differences can create significant barriers to prompt claims payment.

Workers’ compensation carriers in California, for example, are required to pay a clean electronic claim within 15 days of receipt, compared with paper claims that give payers 45 days of leeway between receipt and payment. Orthopedic practices cited in a report say they are receiving reimbursement for electronic claims within 10 days and with fewer claim rejections.

For medical office billers, workers’ comp claims vary significantly from those required for private insurance or federal payers like Medicare or Medicaid, which can lead to difficulties producing clean claims and receiving timely reimbursement. Workers’ comp carriers require extensive documentation to accurately describe the on-the-job illness or injury, detail a treatment plan, and show how subsequent visits and/or treatments are progressing the patient back to health/mobility as outlined in the treatment plan.

Lack of adequate documentation delays payment and creates a significant burden on practices. There has to be a better way.

Many claims management systems are difficult to use

Providers need a claims management software system that readily accommodates attachments, a feature that remains aspirational for many software vendors. Sure, vendors may offer a hard-to-navigate portal or some odd upload option that doesn’t work half the time. What billers want is an attachment system that’s as easy as creating a PDF, clicking the “attach” button, and pressing “send” to transmit the claim and the proper documentation as a single document.

For billers facing difficulty with their claims management system, one common workaround is to send paper copies of the claim, which takes much more time and increases accounts receivable (A/R) days. Billers who file electronically might also wait for the inevitable rejection or request for more information, which often includes a barcode that must be included with the additional documentation to synch up the claim and the paperwork. When the objective is to receive the proper reimbursement in the least amount of time, neither of these methods will produce the desired results.

What to look for in claims management software

Like other types of software a medical practice uses, claims management software should work for users and not the other way around. As practice veterans know, however, the advent of new software often requires the practice to reconfigure workflows to accommodate how the software needs information to be presented.

Look for software that accommodates the types of claims the practice files most often. Can the same software handle private insurance, Medicare/Medicaid, and workers’ comp? If the practice is a rural health clinic, can the claims management system also easily handle those claims?

Practices also need claims management software that analyzes claims for potential denials on the front end. The software should present any claims that need a second look as a notification, much like smartphone users get calendar reminders for upcoming appointments while using their phones. Proactive notification lets billing staff reexamine flagged claims for anomalies and resubmit them immediately, rather than wait for a denial, a process that could take weeks. Denials consume staff time and resources to resubmit, and a large percentage of denied claims are never resubmitted for reimbursement.

Any claims management system should support the quick and easy attachment of notes and documentation that must accompany certain claims, such as workers’ compensation.


While patients likely consider physicians as their healthcare heroes, billing and claims staff are the heroes of the practice, working hard to ensure that office visits and procedures are billed correctly the first time to maximize revenue and speed reimbursements that are the lifeblood of every practice.

Utilizing a robust claims management system can help billing staff perform their tasks more efficiently and with a higher clean claims rate that can mean the difference between speedy payments and denials that slow the reimbursement process even further.

Rob Stuart is founder and president of Claim.MD, a leading electronic data interchange (EDI) clearinghouse helping to streamline the billing and collection process for providers, payers and software vendors.

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