* 90day filing deadline on claim submission. Claims not received within 95 days will be denied and the provider will have no recourse for reimbursement, unless proof of claim receipt before 95 days can be established. If your practice is not following up on claims in a timely manner, you could lose thousands of dollars due to new deadline guidelines. Physicians Choice's office policy is to follow up on account receivables every 30 days. In addition, claims will be submitted with proof of timely filing from our office.

 

* Insurance carriers will eventually be required to accept electronic billing. However, this has not been approved and almost all workers compensation carriers are not set up to accept electronic billing. As of now, providers must continue to bill claims paper with supporting documentation and insure that these claims are received within 90 days. Electronic billing, when and if it happens, will provide a safety net for claim submission, as confirmations will be proof of timely filing. Physicians Choice is set up to bill all other carriers accepting electronic claims and can make this transition for your practice at a price that is affordable. You will have access to your account receivables and patient demographics without having to purchase expensive software to meet these requirements.

 

* Workers compensation insurance carriers are in the process of forming "networks". By 2007, or sooner if ordered, the ADL will be abolished and any provider that is not in "network" with a workers compensation carrier will not be eligible to be reimbursed except under emergent or "pre-approval" situations and/or if the employee resides out of the employer's network area. Employee participation is MANDATORY when the employer chooses a network plan and the worker lives in the network service area. Networks are required to sign written contracts with each provider or group of providers that participate in network. To participate in a network, you will be given a contract to review. Please review your contracts carefully, as the networks will be determining treatment guidelines, return to work guidelines, preauthorization requirements, treating doctor requirements, and "allowable reimbursement" for services. HB 7 allows for insurance carriers to pay above or below the Division's fee guidelines if they are contracted with a provider. These networks will also designate the specialty of doctors that may serve as treating doctors. Insurance carriers will be applying for network certifications with TDI on 01/04/06. Physicians Choice offers credentialing services to help you through this tedious process.

 

* All network fee disputes are to be handled through the network's internal complaint process. This includes payment to "Non network" providers under certain circumstances. Medical Necessity denials requires in network providers to attempt to resolve issues through the network's internal dispute resolution process and if not resolved there, to be resolved by an Independent Review Organization. Good news..... ALL IRO REVIEWS ARE PAID FOR BY THE INSURANCE CARRIER! No more out of pocket IRO fees for providers. Disputing parties can not longer appeal a Division medical fee or IRO decision to SOAH. Physicians Choice offers dispute resolutions services to assist you in getting your claims PAID!

 

* Physical and occupational therapy services will need preauthorization. Certified networks are not required to abide by the list of services required to be preauthorized and may develop their own preauthorization requirements. You must read your contracts to determine what services require preauthorization under each network. Physicians Choice offers practice management solutions to assist you in your preauthorization and practice needs.  NOTE: THIS PREAUTHORIZATION RULE WAS TO TAKE EFFECT 9/1/05. HOWEVER ON 8/30/05, TDI PLACED THIS ON HOLD UNTIL A NEW RULE IS ADOPTED BY THE COMMISSIONER OF WORKERS COMPENSATION. CURRENTLY, THE TWCC RULES REGARDING PREAUTHORIZATION REMAIN IN EFFECT.

 

* If a network insurance carrier accepts the treating doctor's medical examination report defining the compensable injury, the carrier may not deny any medical care on the basis of compensability. However, the carrier can still deny for medical necessity reasons. If the carrier does not accept a specific body part or diagnosis as compensable, the carrier can request that any medical treatment related to the area be preauthorized. If the carrier disputes compensability, they must notify the network healthcare provider in writting. The carrier is liable for a maximum of $7,000 for medical services provided prior to the notification. Physicians Choice stays up to date and current on insurance guidelines that effect your practice reimbursement. More importantly, we train your staff and keep them informed on guidelines as they change.

 

*IF YOU ARE A TRAVELING DESIGNATED DOCTOR, DO NOT SIGN UP FOR ANY NETWORKS! HB 7 states that a doctor may not serve as a designated doctor or a RME for a worker who is receiving medical care through the network if that doctor has a contract or is employed by the same network! The list of issues a designated doctor can resolve has been expanded to include extent of injury; the ability to return to work; whether a worker's disability is a direct result of the compensable injury; and other related issues. The Commisioner of WC may adopt rules establishing the qualifications for designated doctors. The Division's Medical Advisor is required to increase scrutiny on the quality of designated doctor examinations and the division may impose sanctions on designated doctors, including suspension or deletion from the divisions designated doctor list. The Commisioner of WC will adopt rules to ensure that a designated doctor has no conflict of interest when performing an examination. Physicains Choice offers extended services to Designated Doctors, such as scheduling, practice management, submission of narrative reports with TWCC 69 forms in a timely manner, set up of transcription services, and medical billing services.

 

Every medical practitioner on the ADL knows that when you are dealing with workers compensation claims vs. all other insurance carriers its a whole new ball game. Knowing what to do and when to do it on workers compensation medical claims can be overwhelming for many practices. The workers compensation system is a dynamically changing market and keeping up with all the guidelines in addition to providing patient care is almost impossible for most practices.