labor lawAdivision of labor law center

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.

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.

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.

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.

The state of North Carolina’s Industrial Commission wants to make the whole workers’ comp process more efficient and effective for the state’s employers. Part of this is allowing them to have better insurance companies to pick from. Part of it is making a lot of the submission and reporting process digital or online. But a large part of it is also streamlining the medical billing and reimbursement process, whereby injured employees pass along their workers’ comp medical bills either directly to the workers’ comp insurance company or to their employer, who then passes on the billing to the insurance companies.

The converse of this is the reimbursement process, whereby the medical providers or the employers are then paid back for the workers’ comp medical expenses, whether in full or whatever is due according to the particular workers’ comp policy wording that you have.

In any event, the North Carolina Industrial Commission is hoping to be sure that each and every time one of these medical bills is submitted—no matter who is submitting it—that the same information, in the same format, comes through to them. This will make their job easier to process all of these claims, and get the reimbursements headed out the door. Not only the medical bills, but this uniform info must also be on the so called Explanation of Payment that goes along with each medical bill payment.

These new changes came about in part because of work done as far back as 1999 by the Task Force of Medical Provider and Carrier Representatives, which had a huge discussion of these issues way back then. But then in 2005 and 2006, the North Carolina Industrial Commission’s Advisory Council Medical Bill Task Force updated these rules. This task force was made up of medical professionals, insurance companies, lawyers, PPOs, and employers.