Maximizing Reimbursement in Worker Rehab

Nicole Matoushek, PT, MPH, CSHE, CEES

ErgoRehab, Inc.

CLINICAL MANAGEMENT IN WORKER REHAB
Applying clinical management strategies to worker rehab can help the rehabilitation provider to obtain optimal levels of functional outcomes. One of the functional outcomes measures that the rehabilitation provider may be concerned with is reimbursement. Active clinical management can help maximize reimbursement in worker rehab.

REIMBURSMENT PROGRAMS
In workers' compensation, there are several types of reimbursement programs available to therapy providers. These may include fee for service, pay per day or case rate programs. Independent of the reimbursement program that you are in, active clinical management of the skilled therapy for the injured worker can help to ensure payment for all services that are provided and reduce the number of claims denials.

Additionally, ensuring that the therapy documentation supports the billing will minimize billing errors and help you to achieve maximal reimbursement for therapy services rendered.

Many third party claims management systems perform utilization review over the provision of skilled therapy services in workers' compensation. During this review process, the third party administrator may hold further treatment authorization until a concurrent review of medical necessity is performed and the need for continued skilled treatments is determined.

In addition, some third party claims systems perform retrospective reviews in which they may deny payments for services which were already performed. The therapy provider who performs active clinical management in worker rehab will be performing only medically necessary treatments and will be armed with the documentation to support the medical necessity of the treatments. This is one of the most effective methods of ensuring maximal reimbursement for rehab services.

CLAIMS REVIEW OR APPEAL PROCESS
Often times a third party administrator may offer a claims review or appeals process. In order to maximize reimbursement in the event of claims review, here are some recommendations:

1.) Upon receiving a claims review request for information, respond with the required documentation within 7 days.

2.) Prepare your response: review the chart, daily notes, evaluation and progress summaries. Make sure the documentation is complete.

3.) Highlight the following clinical documentation for the claims reviewer:

-Functional deficits.
-Rehab goals.
-Baseline status on functional tests and measures.
-Objective, measurable progress.
-Explanation for lack of progress.
-Residual clinical deficits or problems.
-Indications of clinical outlier and supporting documentation.
-Additional recommendations for further interventions.

Despite your best efforts, there may be times when you feel further medically necessary care is being denied or reduced. Or, the third party claims management system may deny the services that you have already provided. In either event, consider contacting the payer and advocating your position through their appeals process.

When filing an appeal for authorization for further treatment or for payment for services already provided, following these steps will help ensure maximal reimbursement:

1.) Contact the claims management company or third party administrator and request an appeals form or details about their appeals process.

2.) Ask the reviewer for the reason for the denial.

3.) Review the payer contract language and definitions of medical necessity as it pertains to the services you are appealing for.

4.) Inquire what additional, clinical information would be required in order to support your position and obtain approval for further treatment or reimbursement. Inquire how the care meets the contract or health plan's coverage criteria.

5.) Treat the reviewer as a colleague, not an adversary.

6.) Appeal only the claims where you have a legitimate case and can provide objective clinical documentation to support your position. This will ensure your credibility.

7.) Prepare a cover letter and submit the appeals for, cover letter and all supporting clinical documentation to the claims reviewer. In most cases, quality documentation is preferred over quantity of documentation.

8.) In some cases, forward your documentation and position to the ordering physician and request that you sign or provide a letter of medical necessity supporting your request.

9.) Provide education or additional clinical research to the reviewer if necessary. Sometimes the reviewer just requires a better understanding of the situation.

In most cases, this process will result in successful outcomes and appropriate authorization and reimbursement. In the event continued issues occur, contact your state or national professional association, as they may be able to provide references and suggestions to you.

SUMMARY
In summary, worker rehab is a specialized niche of therapy care. Worker rehab includes; work-specific assessments, goals, treatments and specialized programs targeted at the safe, prompt and appropriate return to work of the injured worker.

Functional outcomes, reimbursement, therapy provision, quality of clinical care, patient satisfaction and program development can all be enhanced by developing core competencies in the clinical management of skilled therapy of the injured worker.

Nicole Matoushek, MPH, PT, CEES, CSHE

More information about ErgoRehab, Inc. courses

Other articles by Nichole:

Prompt Return to Work

Injury Prevention: The Shoulder Joint

Anthropometrics and Ergonomics

The History of Ergonomics

Why Offer Return-to-Work Programs?

What is Ergonomics?

Work Injury Prevention and Management

The Cost of Work Related Injuries

Ergonomics and Work Efficiency

Functional Outcomes in Worker Rehab

Conquering Barriers in Worker Rehab

Maximizing Reimbursement in Worker Rehab

Clinical Management in Worker Rehab

Work Injury Consultants

Marketing and Selling Ergonomics and Worker Rehab Services

The Economic Burden of Workplace Injuries

Keyboard Design

Health Ergonomic Objectives

Ergonomics: Work Design Principles

Ergonomics and Muscle Fatigue

Work Modifications using Administrative Controls

Ergo Guidelines for Seating Equipment

Office Setting Ergonomics

Ergonomics: Evaluating Mouse Features

Ergonomics: Evaluating Keyboard Features

Ergo Guidelines for Input Devices

Ergo Guidelines for Office Accessories

Ergonomics/Posture Tips for Laptop Users

Laptop/ Computer Keyboard Design

Sports Medicine Approach to Industrial Rehab