Treating injured workers in any state is complicated, to say the least.

Of course, some states do better than others at informing providers of their rights and responsibilities. Take Texas, whose Division of Workers’ Compensation (TX DWC) makes information readily accessible to providers through its excellent, comprehensive website.

This transparency allows providers to find precisely what they need to know—making it much easier for daisyNews to share the most critical points.

With that, below we present the five important tips (some of which are legal requirements) every provider in the state should remember when billing for the treatment of injured workers.

Plus, see a special bonus tip that the good folks at the TX DWC definitely want providers to know.

Tip 1: Determine Whether a Health Care Network (HCN) Applies

According to the TX DWC, about half of injured workers must seek treatment within one of the state’s 26 certified workers’ compensation Health Care Networks (HCNs).

HCNs are groups of providers to which an employer or insurer restricts their injured employees for cost and quality control. The billing and payment rules for injuries treated within an HCN differ vastly from those treated outside an HCN.

For example:

• HCNs are not bound to pay at state fee schedule reimbursement rates (which in Texas amount to roughly 207% of Medicare rates). HCN rates may be contractual and vary from network to network.
• There is a separate process for disputing incorrect payment denials or adjustments within an HCN which differs from the Medical Fee Dispute Resolution (MFDR) process for non-network claims.
• Required supporting medical documentation may vary from the requirements for non-network claims, or differ from one HCN to another.

…which means that one of the first things every provider should do upon intake is figure out whether an HCN applies.

Suppose the provider is not a member of the applicable network—in that case, they may not be eligible to treat the injured worker unless certain exceptions (such as approval from the network) apply.

Tip 2: Don’t Bill the Employer

So we’re clear: A Texas provider can bill the injured worker’s employer directly for treatment rendered—but providers should consider the possible downsides.

According to Texas Administrative Code (TAC) Rule Section 133.20, the provider may bill the employer “if the employer has indicated a willingness to pay the medical bill(s).” But in so doing, the provider waives the following rights:

• The right to timely payment, outlined in Texas Labor Code Section 408.027
• The right to interest for delayed payment, outlined in Texas Labor Code Section 413.019
• The right to medical dispute resolution, outlined in Labor Code Section 413.031

Every provider is free to choose, but we can’t think of a good reason to surrender the legal right to be reimbursed promptly or seek dispute resolution.

Tip 3: Don’t Bill the Injured Worker

Billing an injured worker, rather than the claims administrator, could land a provider in hot water.

Texas Labor Code Section 413.042 mandates that there are only two situations in which it is acceptable to bill the patient for workers’ comp treatment:

• If the injury is finally adjudicated and not compensable under Subtitle A of the Texas Workers’ Compensation Act
• If the employee violates Labor Code Section 408.022 regarding the selection of a doctor and the doctor was unaware of the employee’s violation when services were rendered

Otherwise, a provider who bills the injured worker has committed an administrative violation, subject to penalties.

Tip 4: Include Required Medical Documents

The requirements for including supporting medical documentation with every bill are lengthy and complex and (as mentioned above) may vary depending on whether a certified HCN is involved.

There’s too much to cover in detail here, so be on the lookout for a future article in which we’ll break down what providers must include. For now, providers should remember a few universal requirements:

• Per TAC Rule Section 133.210, “Medical documentation” includes all medical reports and records, such as evaluation reports, narrative reports, assessment reports, progress reports/notes, clinical notes, hospital records, and diagnostic test results.
• Per § 133.210, required documentation must be “in legible form” unless that documentation was previously provided to the insurance carrier or its agents.
• Per TAC Rule Section 133.20, providers shall indicate on the bill if documentation related to the bill has been submitted.
• Per § 133.20, providers have 15 days to comply with a request for additional medical documentation related to a bill or to send notice that the provider does not have the documents requested.

Tip 5: Bill Electronically!

Here’s a rule that providers should be happy to follow—and we’re not just saying that because we offer the best workers’ comp e-billing software on the market.

e-Billing is faster, easier, less costly, and more sustainable (both financially and environmentally). The right software will track the life cycle of every e-bill, making it vastly easier to manage revenue and ensure correct, timely reimbursement.

More to the point, Texas requires providers to e-bill for workers’ comp. TAC Rule Section 133.10 mandates that providers “must submit medical bills for payment in an electronic format” in accordance with the technical requirements found in Rule Sections 133.500 and 133.501. The only exceptions are:

• If the billed insurance carrier is exempt from the state’s requirement to accept e-bills
• If the provider employs fewer than ten full-time employees
• If the provider rendered services to 32 or fewer injured workers during the preceding calendar year
• If the provider can “sufficiently demonstrate electronic medical bill implementation will create an unreasonable financial hardship” and produce documentation demonstrating as much.

Bonus Tip: Don’t Bill the TX DWC

Having attended several of the TX DWC’s super-informative provider webinars, we’d like to echo a specific, very reasonable request from the presenters: don’t send a bill to the TX DWC or call them about bill status.

As DWC representatives felt compelled to remind webinar attendees more than once, the DWC does not pay doctors to treat injured workers. That’s the insurer or employer’s responsibility.

The DWC offers loads of help through CompConnection, answering questions and clarifying laws and regulations. However, the hardworking CompConnection staffers cannot check a bill's status because they don’t process bills. For the love of comp, don’t call or email them about that.

Providers are also welcome to reach out to daisyBill with any workers’ comp billing questions—regardless of whether or not they’re a daisyBill client. Just use the Chat feature located in the pink bubble at the bottom right corner of this page, or email our experts at info@daisybill.com. We’re here for you!

Nationwide, daisyBill increases revenue and decreases hassle for providers who treat injured workers. Get a free demonstration below.

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