Workers' Compensation
A. Collection: rates, bills, settlements
Prepared by members of Oregon Workers' Compensation Attorneys
Presented to you by Swanson, Thomas, Coon & Newton.
1. What forms are required for billing?
DCBS Form UB-92 or Form HCFA-1500. (Both will soon be found in the annex to this guide.)
2. Does the worker have to receive a copy of the bill?
No. Medical providers are no longer required to send a copy of the bill to the worker unless the worker requests, in writing, copies of the bills. But under certain circumstances (see question 6a) it is wise to do so.
3. Is the workers' compensation carrier required to pay the full billing?
The insurer may not pay more than the medical provider's usual fee to the general public and shall in no case pay more than the 75th percentile of the usual and customary fees as determined by the Director of DCBS.
4. Can a doctor bill a patient for any amounts not paid by the workers' compensation carrier?
For a compensable claim, i.e., an accepted claim, the medical provider may not bill the injured worker for unpaid portions of the billed services, unless the billings arise from unauthorized palliative treatment.
5. Can a doctor bill a patient for unpaid bills?
Only when a claim is denied, or
When a Disputed Claim Settlement (DCS) is reached, or
When the doctor and patient proceed with a course of palliative care after the patient's condition has become stationary and in the absence of insurer pre-authorization.
6. When can medical providers protect themselves while claim acceptance is being decided?
Providers should send correct and complete bills to the workers' compensation carrier as soon as possible, and no later than 60 days following provision of services.
Providers should at all times be prepared to document clinical findings demonstrating the medical propriety of a prescribed course of treatment.
Doctors may not take any collection action against an injured worker so long as the claim is in litigation.
7. What happens if an injured worker settles a denied claim on a Disputed Claim Settlement (DCS) basis?
Each bill may be paid up to 50% of its audited value, to a maximum of 40% of the net present value of the total settlement. Payment is pro-rated among all the providers.
Medical providers may not seek recovery of the unpaid portions of their bills directly from the injured workers beyond the audited amount.
8. What should a provider do if the insurance carrier is not paying medical bills on an accepted claim?
Contact the claims examiner and demand payment.
Keep a precise log of all calls: names, times, contents.
Keep copies of all bills showing date of bill and insurer's name. The doctor may need to prove date the bill was sent to the insurer.
If the bill is not paid within 45 days of billing on an accepted claim, call the DCBS Medical Review Unit at (503) 947-7816, or write them at 350 Water Street NE, RM 27, Salem, OR 97301 and request a review of the matter. They can be very effective.
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Collection: Rates, Bills, Settlements | Aggravation | Communication with Attorneys, Insurers and Patients | Notices for Return to Work and Modified or Light Duty | Report Writing, Magic Words; Standards for Injury, Aggravation and Occupational Disease | Treatment after Claim Closure and in Aggravation Situations | Time Loss Authorization
Last update: June 1, 2001