Workers' Compensation Physical Therapy Guidelines for PTs

Need to know how to handle workers' compensation for your PT practice? This post is for you!

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Workers' Compensation Physical Therapy Guidelines for PTs

Physical therapy practices are no stranger to worker’s compensation claims. In fact, there are 3.4 workers’ compensation claims filed for every 100 full-time workers each year; and a considerable amount of injured employees find themselves at a physical therapist’s office for treatment. The only question is, how should providers navigate workers’ compensation physical therapy guidelines? While treatment for a work-related injury or occupational disease is often straightforward, the details surrounding workers’ compensation billing guidelines are often confusing — not to mention, they also vary by state. Here are five best practices for how physical therapy practices can navigate workers' compensation authorization and billing, as well as a collection of helpful resources.

Navigating Workers’ Compensation Claims in Your PT Practice

For physical therapy practitioners to receive the compensation they’re owed for treatments rendered, the practice must adhere to physical therapy billing guidelines. These rules and regulations for physical therapy billing help ensure a provider is paid on a timely basis and help avoid costly and time-consuming documentation errors. Fortunately, workers’ compensation billing isn’t too far removed from typical authorization and billing best practices. Rather than verify a patient’s insurance benefits eligibility, a therapist must confirm the injury falls under workers’ compensation and then utilize the appropriate claim forms. Here’s a step-by-step approach to workers’ compensation physical therapy guidelines.

1. Confirm the Patient's Injury is Work-Related

The first step to initiate workers’ compensation billing guidelines is to confirm the patient's injury is work-related. Suppose a patient fails to inform a physical therapist that their injury or illness is work-related. In that case, the provider will bill the patient’s primary payer for all services or procedures rather than the patient’s workers’ compensation insurance. This can cause several problems. First of all, if the primary payer has already paid the provider, the workers’ compensation will still need to be billed. The reimbursement from the primary payer must be returned, resulting in a lot of paperwork and resubmissions. Secondly, there’s a chance that the workers’ compensation claim will be denied, as the provider has technically been reimbursed already. From here, an appeal must be initiated, which can cause the practice hours of unexpected administrative work.

2. Verify the Details on the Workers’ Compensation Claim

Once a provider has confirmed that the patient's injury falls under workers’ compensation benefits, they must verify the details on the individual workers’ compensation claim. In most cases, a workers’ compensation claim will include:

  • Name of the adjuster
  • Name of the patient
  • Claim number
  • Patient date of birth
  • Date of the injury 
  • Affected body part that relates to the claim 

Likewise, many workers’ compensation insurance carriers require that the approved diagnosis — or the accepted diagnosis under the Office of Workers' Compensation Programs (OWCP) list of accepted conditions — is included on the workers’ compensation claim. If the physical therapist is not the provider who made the initial diagnosis, they must be aware of it to begin treatment.

3. Contact the Adjuster for Treatment Authorization

After the patient’s eligibility and workers’ compensation claim details have been verified, a physical therapist must contact the adjuster listed on the claim. This conversation must occur before treatment begins. The adjuster will inform the physical therapist if the workers’ compensation insurance is part of a payer network, which will decide where the therapist will submit their claims. Next, a provider must obtain a hard copy of treatment authorization. Verbal confirmation is essentially useless if the claim is denied, as the provider would only have word-of-mouth approval as evidence. A physical, written confirmation helps prove the adjuster authorized the treatment so that therapists can be adequately compensated for all services rendered.

4. Track Each Authorized Visit with Detailed Documentation

It’s important for physical therapists to track all authorized visits, as claims will be denied if the dates of service or visit count differ from the approved diagnosis specified in the treatment authorization. The payer may deny any claims for future service dates if a physical therapist reaches the end date of the authorization, even if the patient has authorized visits remaining. To safeguard their right to compensation, a physical therapist must contact an adjuster as soon as possible if a patient requires additional treatment. Similarly, many payers have workers’ compensation physical therapy guidelines that require providers to submit patient documentation with the claim. Be sure to attach the appropriate documentation as treatment is rendered.

5. Maintain Proper Workers’ Compensation Billing Guidelines

Lastly, workers’ compensation billing guidelines largely focus on the proper forms to submit for reimbursement. These forms include:

  • First Report of Injury Form, which should be completed by the initial provider when the patient first seeks treatment for a work-related illness or injury. 
  • CMS-1500 Claim Form, which the provider’s billing department should submit along with the provider’s documentation for accurate reimbursement. 

Bear in mind that workers’ compensation insurance has no deductibles or copayments to be collected from patients. Instead, providers must accept the reimbursement from the payer as payment in full. Balance billing of the patient is strictly prohibited in workers’ compensation claims.

Resources for Workers’ Compensation Guidelines

While the five above steps are crucial for navigating the workers’ compensation claim process, PT professionals should still note various readily available resources to help support a smooth billing process. Discover these top four workers’ compensation resources.

  1. Regulations by StateWorkers’ compensation physical therapy guidelines and claim requirements may differ from state to state. This American Physical Therapy Association (APTA) resource provides each state’s compensation authority website and relevant PT therapy claim requirements. If you hit a roadblock in the claim process, be sure to refer to the contact information for your state's Division of Workers’ Compensation. 
  2. Workers’ Compensation Medical Cost Containment: This study supplied by The Workers’ Compensation Research Institute (WCRI) covers critical features of each state's workers' compensation cost containment initiatives, including medical fee schedules, treatment guidelines, and medical dispute regulations. Refer to this resource to compare compensation costs and avoid unnecessary treatment costs. 
  3. Workers’ Compensation Medical Fee Schedules: Also supplied by the WCRI, this study highlights the various reasons why the 43 states with fee schedules established their current rates. This resource can be used as a guide for PT professionals to understand their state's specific fee schedules better and ensure fair reimbursements. 
  4. Office of Workers' Compensation Programs Medical Bill Processing Portal: From the Federal Office of Workers’ Compensation Programs (OWCP), this tool is to be used by PT practices to bill for services provided to claimants who have been approved for one of the four OWCP benefit programs. These programs include the Federal Employees Program, Energy Workers Program, Longshore Program, and the Black Lung Program.

The Bottom Line

When it comes to navigating workers’ compensation physical therapy guidelines, there’s no such thing as too many resources. Check out the MWTherapy Blog for more information on physical therapy billing best practices. To streamline your workers’ compensation documentation and billing, leverage an effective physical therapy practice billing software like MWTherapy. Book a demo today to learn how robust billing software can improve your PT practice.

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