Workers’ Comp Claims Process: Understanding the Steps Involved

Posted by Susan Berndt on April 27th, 2020
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Susan Berndt
Susan is a creative marketing professional with a demonstrated history of working in the hospital & health care industry. Susan joined Smart Data Solutions in 2016 focusing on marketing strategy, campaign execution and creating an inbound marketing funnel. She has over 10 years of marketing/advertising experience and over 12 years of customer service experience.

If you’ve never had to file a workers’ comp claim, they can be a little complicated to understand. There are numerous steps involved, and it requires the diligence of both the employer and the insurer to file the claim correctly.

Thanks to the help of property and casualty businesses, or other front-end providers, all parties involved can get the support they need to work through the process. We’ll be breaking down workers’ comp claims, starting with the basics, and then going through our P&C Workers’ Comp process here at Smart Data Solutions.

Workers’ Comp Claims Process – The Basics

Minnesota Statutes 176.181, subd. 2, requires all employers to have workers’ compensation insurance, with some restrictions listed within Minnesota Statutes 176.041. Different states have different laws regarding workers’ compensation benefits and insurance. Therefore employers and insurers need to disclose that information to employees.

Worker’s compensation falls under property and casualty insurance. This coverage is required for any injuries that occur due to the job or on the job site. This coverage aids those employees who were injured, disabled, or deceased on the job resulting in lost wages, medical expenses, and rehabilitation costs.

What Does an Employee Need to Know When Filing a Workers’ Comp Claim?

Employees can always refer to their insurance documents or portal for more information. The Minnesota Department of Labor and Industry also has a helpful FAQ page on their website for all of your state laws regarding workers’ compensation.

If an injury occurs on the job, it’s important to get medical attention immediately and to report the injury as soon as possible. Not reporting the injury right away, can affect compensation coverages if it is out of the state-mandated time frame. Employers then file a First Report of Injury, or FROI, with the insurance provider.

The workers’ compensation claim is submitted through the provider and either approved or denied. In the case of a denial, appeals can be filed, or the injured party can contact a resolution specialist to help along the way.

What Can a Payer Expect When Filing a Workers’ Comp Claim? 

First, from the Provider’s perspective, they would file the medical bill. Providers don’t generally do anything different from processing a standard medical bill. The primary difference is that the policyholder listed would be the company, not the employee. This ensures the bill is paid through the workers’ compensation benefits package.

From the payer’s perspective, they can expect bills to be submitted to them as an 837 form or electronic claims attachments as 275 forms. In some cases, the providers also submit medical bills on paper, especially if the supporting documentation can not be sent electronically via their systems. Payers may have to wait for claim matching procedures or report detection to ensure the right claims are paid in full, under the appropriate benefits.

Are There Any Stipulations That Could Cause a Claim to be Denied?

Aside from the failure to report a work injury on time, there aren’t many things that would deem an employee ineligible for their benefits. Submission for claims denial works similarly to a typical medical bill completion, following standard compliance requirements.

Where Does Smart Data Solutions Come into Play in Regards to Filing WC Claims?

First off, the term “claim” means something very different in the realm of worker’s compensation. In this case, “claim” refers to the actual claim being filed, while “bills” refer to each medical bill processed to the payer or provider. This differs from the commercial healthcare space where we generally refer to every medical or dental bill as a claim. While nuanced, this slight vocabulary difference means two completely different things to a P&C payer v. a health care payer.

As we had discussed earlier, a key component in the bill submission process is the receipt of a First Report of Injury. This report is filed between the employer and the insurer and would notify the claims processors of the beginning of the WC claim. Depending on the payer, this may also be in the form of the First Report of Loss. In some cases, this process gets skipped over. In this case, the first medical bill to come through would be our first notification of the workers’ comp claim. From our standpoint, either of these can begin the process of setting up a “claim” with our client.

When a medical bill is submitted through our system, we also receive an extract of active claim cases from the applicable payer. We match up the bill to their active case, or if there is no active case, we can assist our payer in determining if it is the first initial report. We do this by triggering an event in their claim system or routing the bill to an FROI specific queue for their team to view and set-up the claim.

At Smart Data Solutions, we know the differences between a workers’ comp claim and a run of the mill medical bill. Knowing this ensures proper handling of those critical workers’ compensation claims. We also know that different payers have systems that may or may not support automated workflows. Some clients leverage the SDS workflow solution to automate processes.

Our clearinghouse is well-versed in identifying the first report of injury or loss, and how to process those correctly. We also have everything necessary in our clearinghouse to support electronic claims filing and bill workflow. For more information on our workers’ comp claims process, check out the website here.

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