North Carolina Employee Benefit

May 22nd, 2007 Posted by Amelia

A new extension to The Mental Health Parity Act, or MHPA, was recently approved and signed by the president. The new expiration date will be December 31, 2007. The law was initially endorsed in 1996 and included a clause that determined that the act must end on September 31, 2001. However, the expiration date was extended a total of five times.

Many North Carolina employee benefit plans are affected by the extension of the MHPA. The MHPA requires that any health insurance plan must provide the same benefits for treatments related to mental health, as for other medical treatments. Prior to the approval of this act, it was normal for the insurance plans to offer low coverage for mental health, and much higher limits for other medical treatments. It was a common practice to cover mental health treatments only up to $5,000 to $10,000, while the coverage for other treatments could be $100,000 or more.

Appointments to a psychiatrist or therapist are examples of mental health treatments covered by many insurance plans. Often, they also include admission to health centers, or hospitals. Some mental conditions like schizophrenia may require extended treatment in specialized clinics. Rehabilitation of patients with drug or alcohol problems may also be covered.

In 1974, the federal agency that enforces the law regarding pensions and healthcare was created. The agency’s original name was the Pension and Welfare Benefits Program, and it had the responsibility to enforce the Employee Retirement Income Security Act approved in 1974. In 1986, the agency’s name was changed from Program to Administration, and the new name was the Pension and Welfare Benefits Administration. Today, the actual name is the Employee Benefits Security Administration, or EBSA. This has been the case since 2003. At that time, the agency was upgraded in level and is supervised by an Assistant Secretary of Labor.

 

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Medical Bill Operations: The End?

January 11th, 2007 Posted by Mark

Remember all that talk about first reports of injury, those forms that had to always be filled out and submitted to the state and the insurance company any and every time an employee got hurt at your work? We talked a whole bunch about first reports of injury when we studied how each state’s workers’ comp program works, and how injuries must be reported to the workers’ comp system in every state.

You will know learn why they are important—in the context, once again, of the updated labor laws in North Carolina for medical bills and reimbursement for workers’ comp injuries. The importance comes when a medical bill payer—the insurance company or the employer—gets a bill that has no corresponding first report of injury with it.

When that occurs, the payer—let’s say in this case the insurance company—must immediately contact the employer to see what is going on. Is there really an injury? Was there a workers’ comp claim filed, and why? If you the employer has no idea what the heck is going on, then under the regulations set up by the North Carolina Industrial Commission, the payer then sends that bill back to the medical provider who charged it and tells that medical provider that no such claim exists.

In the case of the insurance company, they are then required to send a copy of the bill and their denial letter—and the exact reason for the denial—to the employer and the employee. If the employee is truly hurt and the workers’ comp claim could be legitimate, then the employee can still file a claim for their workers’ comp related injury, and the medical provider can re-submit the bill to the insurance company.

It’s amazing to think that this sort of give and take happens hundreds of times a month, if not thousands, as workers’ comp claims and injury medical bills sprout up in North Carolina’s office, warehouses, factories, farms, and other work sites.

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Medical Bill Operations: It Doesn�t Stop Yet

January 11th, 2007 Posted by Mark

I can see my readers cringe at the thought of more talk about these medical bill review and reimbursement requirements in North Carolina, but heck, any employer facing injured employees on the job must face them, whether or not they are self insured or whether they have an insurance company for their workers’ comp claims. The simple truth—and I can’t seem to stress this important point enough—is that data is king, and if you can solve how to organize and keep track of all of your personnel records, your Accident/Injury & Illnesses Reports, absence reports, and other human resource documents, you will rule with it.

But as always, I digress. Where were we? Oh yes, all of the important data that must be included with every reimbursement record. Along with info on you and the employee, as well as the charges and what you the payer is paying, you also have to provide info that the North Carolina Industrial Commission requires, like any sort of dispute resolution that was necessary as well as late penalty payment rules.

If you have an insurance carrier and are not the payer, you must also be sure to include the name of your insurance carrier, their address, and the pertinent contact information such as telephone numbers and the name and title of the person to contact there.

If possible, the North Carolina Industrial Commission would also appreciate if you included a carrier claim number for the particular employee and injury, the IC number, and the authorization code for the case.

Last but not least, with your check for reimbursement, the North Carolina Industrial Commission requires that you provide an Explanation of Payment. Not sure if you know what that exactly is? The best way to check is to send in a sample copy of your current Explanation of Payment statement to the North Carolina Industrial Commission.

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Medical Bill Operations

January 11th, 2007 Posted by Mark

Back to this whole medical bill submission and reimbursement issue. When we look at the new requirements facing medical providers, insurance companies, and employers alike, we see that the workers’ comp process is always a data-driven business. Whoever is in charge of the data better be keeping it in good order, and that includes a good use of personnel records, employee injury forms such as an Accident/Injury & Illnesses Report, and the like.

The time frame for all of this information to be passed along to the stake holders is not as short as you might like. For instance, when it comes to medical bills, they have to submitted within 75 days of the service being given. Or if the treatment lasts more than 30 days, then the bills must be submitted within 30 days after the end of the last month that the services were provided. And after the bill is submitted, whoever is paying them—and in cases where you the employer are self-insured for workers’ comp, the payer is you—must be able to produce the same depth of detail that we saw needed from the medical providers.

The payer must provide their organization’s name, their organization’s tax ID, the employee’s name, social security number, followed by the employer’s name (if you aren’t the payer), the patient account number, the date of the injury, the date or dates of medical service provided, and the procedure code for each service performed on the injured worker.

On top of that, you have to provide info you’d expect from a reimbursement of any kind, such as the amount charged and the amount your paying, per each procedure (with each procedure code too). This info must also include the reductions to the workers’ comp fee schedule for North Carolina, any PPO discounts you’re getting, and any other adjustments or non-covered charges.

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Medical Billing Rules Changes: The Explanation

January 11th, 2007 Posted by Mark

What the North Carolina Industrial Commission’s Advisory Council Medical Bill Task Force came up with in their 2005 and 2006 updates is as follows. (And if you have no clue what I am talking about with a commission and an advisory council, please read the entry below in the blog for a clue.

The North Carolina Industrial Commission’s Advisory Council Medical Bill Task Force decided that with every medical bill and with every Explanation of Payment, providers (or those medical professionals actually providing the medical service to the injured worker) had to be sure to include their organization’s name, their tax ID, as well as this info on the patient: the patient’s name, phone number, social security number or ID number, and the patient’s account number with the particular medical provider.

The list of information required of medical providers by the North Carolina Industrial Commission’s Advisory Council Medical Bill Task Force continues to include: the name of the employer involved in the workers’ comp medical issue, the insurance company’s name or the name of the employer or other payer if there isn’t an insurance company involved, as well as the date of the injury, the date of the particular medical service provided (for each medical service provided), the procedure codes for each particular medical service provided.

We continue: the medical provider should also provide the diagnosis codes for the injured workers particular ailment or injury, their admission date, their discharge date, the billed charges per procedure code (for each procedure), and any medical notes or operative reports, along with the phone number and name of the person at the medical provider who should be notified when this claim would be denied (if of course, it does get denied). That is quite a bit of info that employers need to make sure that all of their medical providers, well, provide.

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