The Georgia Scroll
October 1998
Solving Worker’s Compensation Problems
By: Clinton A. Harkins
About two years ago, a patient accounts manager approached me with a problem that was not unique: her day in A/R for her Worker’s Compensation financial class had exceeded 120 days and more than one-half of her A/R for these accounts were over 90 days. She needed to reduce her A/R days as quickly as possible in order to generate much needed cash for her hospital. I explained to her that I felt that we could help her achieve her goal of 75 days for her W/C financial class within six months.
How do we begin to clean-up your W/C financial class? You must first understand the specifics regarding our Worker’s Compensation statute. Worker’s Compensation is administered by the Worker’s Compensation Board under the Worker’s Compensation statute that is codified in the Uniform Code of Georgia Annotated Section 34-9-1 - - 34-9-421. As each of you know, the employer is responsible for the payment of their employee’s medical expenses and a patient may no be billed for any medical expenses that were incurred as a result of a work-related injury. The key to remember is that all collection efforts by the hospital should be concentrated with the employer as insured for W/C claims and employ a third party administrator to pay claims. This procedure is very similar to self-insured employers (ERISA) for their employee’s health insurance plan. Many employers employ the same T.P.A. for both the health insurance plan and for Worker’s Compensation. Please note that if an employee claims a W/C related injury and the employer denies that it is work-related, the employer is still responsible for the payment of the employee’s medical expenses if the employer has a self-insured health insurance plan. If the employer of the T.P.A. denies the claim under W/C, the hospital should demand payment under the health insurance plan and enlist the aid of the employee in getting the claim paid. If the health insurance plan denies payment because the claim is a work-related injury, explain to the self-insured employer that either way, the employer is responsible for the payment of the bill.
The most powerful collection tool under the W/C status is O.C.G.A. : 34-9-203(c). This section provides as follows:
"The board may, in it’s direction, assess a penalty of up to 20 percent of reasonable medical charges not paid within 60 days from the date that the employer or the employer’s worker’s compensation insurance carrier receives the charges and reports required by the board where there has been compliance with the requirements of law and board rules. Said penalty shall be payable to the medical provider."
Rule 203(b)(2) and 203(b)(3) provide as follows:
"(2) For charges not contained in the fee schedule and which are disputed as not being usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the board within 60 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon the employee, if unrepresented, or the employee’s attorney. A party requesting peer review of chiropractic charges or treatment shall attach to the application 10 copies of the charges and all of the reports dealing with the treatment of the injured employee. A party requesting peer review of any other treatment or charges shall attach to the application two copies of the charges and all of the reports dealing with the treatment of the injured employee.
The peer review committees approved by the board are as follows: Metropolitan Atlanta Foundation for Care; Georgia Psychological Association; and Georgia Chiropractic Association, Inc., and such other committees as the board has posted as so designated at its Atlanta office.
(3) Unless peer review is requested as set forth in Rule 203(b)(2), the board may, in its discretion, assess a penalty of up to 20 percent of reasonable charges not paid within 60 days."
Under the law, all bills must be paid within 60 days of the date that the employer or carrier receives the bills. If payment is not made, the employer must request peer review within 60 days from the date of the receipt of the bill to determine whether the charges are usual, customary and reasonable in the State of Georgia. It is our view that if peer review is not requested by the employer within 60 days, the amount billed cannot be controverted unless the amount billed is inaccurate under the schedule.
The only quirk in the law at the present time is does the W/C board have jurisdiction over a claim where the employee did have a W/C related injury, did not file for W/C benefits and the employer was billed by the medical provider but the claim was not paid and peer review was not requested? We are presently testing this scenario to determine whether or not the W/C Board will accept our appeal of non-payment by an employer. If the W/C Board rules that they do not have jurisdiction due to the fact that the employee did not file for W/C benefits, we will attempt to state a claim in state court based on the employer-employee relationship and the failure of the employer to pay for the employee’s medical expenses.
In conclusion, we were able to facilitate the hospital in achieving their goal of 75 days for their W/C financial class. By utilizing the tools available to medical providers under the statute, hospitals can greatly reduce their A/R days for Worker’s Compensation accounts.
Clinton A. Harkins is an attorney who specializes in third party reimbursement and is a former President of the Georgia Chapter of HFMA.
Last modified: June 22, 2001