More on Claims Processing

How to manage MVA and workers' compensation claims successfully

Motor vehicle accident and workers' compensation claims are less common, more complex and often require manual processes outside of normal workflows.

In an era of technology-driven workflows and automated claims processes, most healthcare providers are skilled at billing traditional claims that require minimal manual touches. In contrast, motor vehicle accident (MVA) and workers' compensation claims are less common, more complex and often require manual processes outside of normal workflows. 

While MVA and workers' compensation claims are only a small percentage of a healthcare organization's total claims, they can amount to millions of dollars in annual revenue for many hospitals and secure higher reimbursement rates than commercial insurance. Those potential financial benefits make it essential that providers learn how to process such claims correctly and efficiently.

To ensure timely and full reimbursement while also optimizing patient benefits and care experience, providers must embrace strategies that begin at the initial point-of-service, with complete and accurate insurance information collected upfront. The best way to do so is to leverage the expertise of a third-party patient liaison.

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Uncommon processes

Auto insurance and workers' compensation carriers primarily serve to protect property and businesses. Since healthcare claims processing is not their focus, their systems and technology are not designed to support these transactions. This means that many healthcare claims processes, including eligibility verification, billing, and status inquiries, must be managed differently than traditional claims.

For example, to verify eligibility or inquire about reimbursement status for an MVA or workers' compensation claim, hospital staff must call the insurance carrier directly. Similarly, billing is also done manually, with individual claims submitted via fax or mail rather than electronically. The amount of manual work required makes managing and collecting these claims more costly.

Eligibility rules and requirements also vary from state to state. Hospitals, therefore, must know how to identify which carriers to bill for primary and secondary coverage. For example, Virginia requires that providers bill a patient's commercial insurance first as the primary before billing the auto insurance carrier. In most other states, the opposite applies.

Eliminate patient confusion and eligibility uncertainty upfront

Successful processing of MVA and workers' compensation claims starts with obtaining complete insurance information upfront. If hospitals wait until the patient has been treated and is out the door, it becomes increasingly difficult to recover reimbursement.

Obtaining information upfront can be challenging, however. Fearing rate hikes, patients may be reluctant to provide their insurance information when the accident "wasn't their fault." They also may not understand how their coverage works. Nevertheless, the hospital must find a way to get complete and accurate information at the point of service to determine claims eligibility.

Leveraging patient liaisons

Using dedicated partners – or patient liaisons – can help minimize patient confusion while also supporting more effective billing and reimbursement.

The patient liaison begins the process by screening patients at the initial point of service, obtaining insurance information, accident information and, whenever possible, the carrier's insurance card. The liaison also collects data about the incident, including police reports or other pertinent information, and then contacts the carrier to verify coverage benefits and eligibility.

Once qualification is determined, the patient liaison shares this information with the patient and walks them through the claims process, answering any questions that arise.

Optimizing MVA and workers' compensation claims

Both the patient and the hospital benefit from this support.

Patient liaisons can increase patient awareness around benefits and reduce or even eliminate out-of-pocket expenses. For example, emergency department visits following auto accidents can cost thousands of dollars. Patients are likely responsible for a percentage of these costs because of deductibles, copayments and co-insurance requirements. However, patients may be unaware that their auto insurance carrier will cover some or all of those expenses.

Patient liaisons also can yield benefits to hospitals by decreasing unnecessary expenses and duplicate efforts while helping to maximize staff and resources. Patient liaisons can also increase compliance with billing regulations by ensuring that primary and secondary carriers are billed appropriately. This prevents "double dipping" into health and MVA or workers' compensation insurance coverage, which is a risk when patients and providers are unfamiliar with these types of claims.

While some hospitals use internal liaisons, others choose to outsource this function through a vendor and benefit from their partner's specialized expertise. This approach can help hospitals recover reimbursement even more efficiently and effectively.

For example, 18 months after partnering with a vendor specializing in third-party coverage advocacy, an academic level 1 trauma center with more than 500 staffed and licensed beds was able to increase collections for its MVA accounts by $7 million annually. In addition, it was able to reduce its average billing cycle time on these claims by more than 21 days.

A better way

Regardless of whether hospitals rely on in-house strategies or seek support through a vendor partnership, it is essential that they employ a robust approach to managing MVA and workers' compensation claims.

Because they are rare, complex and outside normal workflow, such claims consume disproportionate resources, yet they can generate significant revenues that bolster a hospital's financial health. Managing these claims successfully starts with obtaining complete claims on the front end. By using patient liaisons, hospitals and healthcare providers can further ensure accurate and timely reimbursement while also enhancing the overall patient experience.

About the Author:

Donald Drummy, senior director of third-party coverage, Change Healthcare