One of our major focuses at EnableComp is to monitor and report on legislative and industrial changes that have material impact to our business. As a national work comp revenue cycle company with over 600 hospital clients across the country, you can imagine that we (and the rest of the work comp community) have been watching Tennessee for quite some time as the changes within work comp have been significant over the past few years. Now with the State moving toward requiring work comp billing to be all-electronic in 2018, there are several points to consider for hospitals to be efficient and compliant with the proposed regulations.
1. Basics of the Proposed Rule:
Legislation was passed in 2013 that enabled the State of Tennessee to adopt rules regarding the electronic submission and processing of medical bills by health care providers to insurance carriers on or after July 1, 2014. Rule 0800-02-26 has been drafted with the purpose of providing a legal framework for electronic billing, processing, and payment of medical services and products provided to an injured employee and data reporting subject to Tennessee Code Annotated § 50-6-202. For consistency, the TN Department of Labor and Workforce Development have used the International Association of Industrial Accident Boards (IAIABC) work comp electronic medical billing model rule and companion guide as benchmarks by which to follow. As such, they are requiring standard electronic formats such as 837, 835 and 277.
These files must be sent and received with a very specific timeframe. Payers must acknowledge receipt of an e-bill file within one business day and must acknowledge acceptance of each bill within two business days. Providers must not submit duplicate bills sooner than 60 days, which is longer than what we at EnableComp see in the industry. Providers must also submit requested documentation within seven business days Additionally, payer must submit rejections for compensability within 15 business days and send Electronic Remittance Advice (EOB) within five business days.
Electronic payment is also required through mutual agreement. The rule states that “All payments for service are required to be paid via electronic funds transfer (EFT) unless an alternate electronic method is agreed upon by the payer and provider.”
The rule does identify penalties of up to $5,000 for Payers that do not properly pay or object to submitted bills timely or fail to maintain compliance with the rule altogether. Additionally, some payers and providers are exempt from this requirement. Payers that process fewer than 250 work comp bills annually or Providers with 10 or fewer full-time employees that submit fewer than 120 work comp bills annually are not required to be compliant with this rule. Also, the Bureau of Workers' Compensation may grant an exception on a case-by-case basis if the payer or provider can establish that electronic billing will result in an unreasonable financial burden.
2. Roadblocks and Recommendations:
Beyond just compliance with the State-mandate e-billing directive, medical providers need to know how to make e-billing work for them. Collaboration with your Registration department is the place to start. Identifying work related injuries (1) Did this injury happen on the job and 2) Who is your employer?) are critical first steps to getting the claim billed correctly the first time. Using the correct employer data, you can cross-reference the payer from your state work comp database as well as authorize the medical procedure per TN Pre-cert rules. (Preauthorization is required for all non-emergency medical services (outpatient and inpatient).
The next hurdle is the classic conundrum with work comp billing: the burden of Documentation. Unlike Group Health claims which are predominately paid based on eligibility, Workers’ Compensation is all about the compensability of the specific injury being treated and the documentation to support that treatment. Payers are well within their rights to deny payment until they receive medical documentation which can and should be submitted electronically along with the e-bill. It’s important to note that providers sending documentation via electronic means must be able to send in PDF format.
The third issue to consider is Payer Acceptance and Standardization. Electronic bills must pass through an eligibility check to be accepted by the payer. Payers can sometimes have unique requirements to pass this check and values must match exactly otherwise the bill may be rejected. Additionally, Payer-specific Requirements such as unique claim numbers, dates of injury and patient demographic information must be addressed beforehand to ensure seamless bill submission.
Insurance companies pay hospitals the correct Fee Schedule amount only 32% of the time! If you don’t know what to expect, you’ll spin your wheels appealing payments and miss other opportunities in the process. While some portion of your work comp patients will have claim jurisdictions outside of your state, along with Federal employees and other anomalies, the vast majority of your work comp claim load should be paid pursuant to the Fee Schedule or Usual and Customary procedures in your state. Most states publish this rate information on their website free of charge, or it can be purchased from a data supplier for a few hundred dollars. Modeling the correct amount for your state’s Fee Schedule is well worth the time on the front end to ensure you are being paid accurately and appealing the correct claims on the back end.
3. What's Next?
First and foremost, review the Proposed rules. They are located on the TN Department of Labor and Workforce Development website: https://www.tn.gov/assets/entities/labor/attachments/Rulemaking_080817_Public_Notice.pdf
Next you will want to decide how your organization is going to become compliant. Make sure you know how you are billing for work comp presently. Are you primarily paper or e-bill currently? Are you successful in making the payer e-bridge? Are you compliant with current rule? Do you get the level of reporting you need to ensure your work comp billing is meeting and exceeding your revenue cycle goals? If the answers to most of these questions are “No”, then bringing in an outside electronic billing partner might be the best way for you to maximize revenue and remain compliant with the state rule.
Lastly, submit comments and question to the State so they can include them in the upcoming rulemaking session. The Bureau will be conducting a public rulemaking hearing on August 8th at 10:00 am CDT. The hearing will be held in the Tennessee Room of the Department of Labor and Workforce Development offices located at 220 French Landing Drive in Nashville.
Jesse Larrison is a 15-year veteran of the workers’ compensation industry. Having held leadership positions for one of the largest work comp payers in the country, Jesse now oversees Managed Care for EnableComp, a revenue cycle company for hospitals. Jesse lives in Nashville and cheers on The Predators with his wife, son and twin girls.
EnableComp is the nation’s leading Hospital Revenue Cycle partner focused exclusively on workers’ compensation. With over $10 Billion in claims processed, EnableComp serves more than 600 hospitals and health systems maximizing revenue and removing the headache of work comp claims billing.