WC Question - Private Insurer Denial

[Guest guest]

Dear colleagues,

The question/comment was posed by a colleague that if the

patient/injured worker refuses to file a work comp claim and then wishes to

bill his private insurance carrier can they not deny payment since your chart

not clearly documents the patient was actually injured on the job.

Answer: (thanks to friend and wc attorney Randy Elmer

of Salem) Yes they can deny and will as nearly all private insurer’s

contracts have an exclusion for on the job injuries. Randy made a very

good point in that he agreed with me/us that we must ethically provide

(document in our chart notes) an accurate history which would include the fact

they were injured on the job. He agreed we must also fully inform the

patient/injured worker that if we bill the private insurer they will deny the

claim and that they will end up owing us for those services. However,

Randy also noted that this puts the doctor in a bad position as the patient can

later with another provider such as his medical PCP fill out a Form 827 turning

the case into a workers’ comp claim without your knowing and then come

back on you/me with a complaint to the W/C Director that we are attempting to

collect X $$$ for outstanding treatment that should be billed to the W/C

insurer.

I would suggest in this situation that if the

patient/injured worker places you in this position that you first fully inform

them of the above consequences, document all completely in your initial chart

note, and then require the patient pay for services on the same day they are

given. For me I will require payment prior to the patient/injured worker

going back to the treatment room. Now if later the injured worker/patient

attempts to file a W/C claim and file a complaint against you, it will not fly….

Hope this is useful information,

Cheers,

Vern sAboe