First of all, you must determine whether there is a valid workers’ compensation claim if the claimant comes to you after there has been some initial care. Of course, if you are the first health provider you will file the Worker and Physician’s Report of Industrial Injury with the Industrial Commission to at least get the claim started. You need to periodically check with your patient to see if the claim has been “accepted” or “denied” by the insurance company. Typically, that occurs within approximately one month of the time the claim is actually filed. It may take a little longer or it may be a little quicker. However, you must ensure from either speaking with your patient or calling the Industrial Commission at (602) 542-4661 to determine if the claim has been accepted or denied. If you continue to treat a denied claim, you may do it at great financial risk.

 

However, once the claim is accepted, you must bill pursuant to the Arizona Industrial Commission Fee Schedule. The workers’ compensation claim payment is limited to the Arizona Industrial Commission Fee Schedule. This Fee Schedule is available on the Industrial Commission’s website: http:www.ica.state.az.us. See, A.R.S. § 23-908B:

 

The Commission shall fix a schedule of fees to be charged by physicians, physical therapists or occupational therapists attending injured employees and, subject to Subsection C of this section, for prescription medicine required to treat an injured employee under this chapter. The Commission shall review the schedule of fees.

 

Healthcare provider reimbursement is limited to those fees established by the Industrial Commission of Arizona Fee Schedule. See, Canyon Ambulatory Surgery Center of Arizona vs. SCF of Arizona, 225 Ariz. 414, 239 P.2d 733 (Ct .App. 2010). Balance billing is not allowed.

 

The rules and procedures before the Industrial Commission of Arizona, Rule 20-5-117 establishes:

 
A. A carrier, self-insured employer, or special fund division, shall pay bills for medical, surgical and hospital benefits provided under A.R.S. § 23-901 et seq. according to applicable medical and surgical fee schedules adopted by the Commission and in effect at the time the services are rendered. A physician or provider of nursing, hospital, drug or other medical services shall itemize and submit a bill for payment only to the responsible carrier, self-insured employer, or special fund division.

 

Another rule in Subsection B indicates that the claimant is not responsible to pay any disputed amounts between the medical provider and the carrier, self-insured employer, or special fund division.
In addition, after your staff places the billing in proper format, there must be a timely billing.

 
A.R.S. § 23-1062.01 indicates that the carrier’s self-insured employer or claims processing representative shall make a determination whether to deny or pay a bill, either in whole or in part, within thirty days from the date the claim is accepted, if the billing is received before the date of acceptance, or within thirty days from the date of receipt of the billing if the billing is received after the date of acceptance. It also establishes that all billing denials shall be based upon reasonable justification.
 
A.R.S. § 23-1062.01 also states that if the billing is not paid within this applicable period of time, the claims processing entity shall pay the health provider on the unpaid billing at a rate equal to the legal rate of interest calculated from the beginning of the date the payments to the healthcare provider is due.
That same statute in paragraph B indicates that the bill must have the correct demographic patient information and the claim number, if known. As well, it requires correct health care provider information, name, address, telephone number and federal tax payer identification number and the appropriate medical coding with dollar amounts and units clearly stated with all descriptions and the clearly printed date or dates of service, as well as legible medical reports required for each date of service if the billing is for the direct treatment of the injured worker. This means that your staff must bill pursuant to the Fee Schedule, with clear legible bills attached to the medical records to support the billing (emphasis supplied).

 

The next important billing issue is the timing of the initial or any bill. A.R.S. § 23-1062.01 indicates that an insurance carrier, self-insured employer or claims processing representative is not responsible for payment of any billings for medical, surgical or hospital benefits provided under this chapter unless the billings are received by the insurance carrier, self-insured employer or claims processing representative within 24 months from the date on which the medical service was rendered or from the date on which the health care provider knew or should have known that service was rendered on the industrial claim, whichever occurs later (emphasis supplied). This means that you should bill periodically and ensure that from the last date of your service. Do not wait more than the 24 months or you won’t get paid.

 

If the claim is in litigation, it would be wise to bill the carrier periodically, even though it is in litigation because at least the carrier has “received” the bills pursuant to A.R.S. § 23-1061.02. In other words, don’t wait until there is some finality to the litigation before you bill. That may take two years! Let them reject the bill and send it back, but at least you have the record that you did bill them during the statutory two-year period.

 

Any questions, please contact me.

 

Robert E. Wisniewski, Esq.
Attorney at Law
519 East Thomas Road
Phoenix, AZ 85012
Certified Specialist, Workers’ Compensation,
Arizona Board of Legal Specialization
Phone: (602) 234-3700
Fax: (602) 230-5759
Email: bob@azhurtonthejob.com
website: azhurtonthejob.com


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