For many claimants, the goal of filing a claim is to “get the White Card” … with the expectation that once you have been approved and received a ‘White Card” that everything going forward will be hunky-dory. Well, as many learn, that is rarely the case. There are many issues that come up which require constant vigilance and follow up with a worker’s various medical providers.
This blog is one of several I am publishing in the hope that the facts and myths are more universally known. In this writing, I touch on Medical Providers, Billing procedures, and common issues with the “White Card”.
Medical Providers and Billing
A medical provider who submits bills must be enrolled in the DOL EEOICPA program and assigned a provider #. All providers are necessarily enrolled in the Medicare/Medicaid national program as well. For a worker with a White Card, any medical service that is related to the ongoing care and treatment of an approved condition can be billed to DOL through an online process by an enrolled medical provider. Providers (through Billing departments) provide SSN, ICD 10 code(s) and Cost Procedure Treatment (CPT) codes (service/procedure codes), date of service, and demographic information to insurance companies and to DOL’s insurance service manager – CNSI.
The coding process starts with the RN/doctor and is passed to an internal billing department or sent to a contracted 3rd party processor. Medical providers reference one or more ICD 10 codes (for a given medical condition(s)) on every bill. Having correct and DOL approved ICD 10 codes for your bills is imperative and the number one largest reason for downstream issues and denied bills. Providers have the option of including details notes in every bill submission. When an initial bill is rejected, or denied due to “non-covered item” (think EOB – explanation of benefits on insurance statements), the billing staff/agent may, and often does, resubmit bills with amended or corrected ICD 10 code(s), CPT codes, or by entering notes explaining how the service was necessary or related to the approved condition.
ICD 10 Codes – Medical Condition and Procedure Coding
An ICD 10 code is the designation for each specific medical condition. You can Google “ICD 10 Code” for any specific medical condition and get a feel for the scheme. From there, a wide variety of service or procedure codes (CPT Codes) are mapped to any one ICD 10 code. For most procedures/services, if a CPT code/service code maps as a standard service related to that ICD condition, insurance companies and DOL automatically pay/process without question. A few services require, or it is requested, that a pre-authorization be obtained before bill processing is completed. If a bill is submitted and the ICD 10 code or CPT code is rejected or declined, it’s usually because the billing staff/agent did not include the primary and original ICD 10 code, and to a lesser extent, the service code does not “normally” map to the approved ICD 10 code. When trying to correct/amend the bill/issue, you almost always must go back to the RN/doctor to initiate a change or amendment.
The bill coding process may list more than one ICD 10 code in a billing record. Trained and certified billing staff/agents are “supposed to” show the history for a patient by starting with the initial medical condition, and then extending to any other ICD code that is related. For example a bill for neuropathy treatment may have an ICD Code for an initial cancer, and then a code for chemo-induced neuropathy.
Billing Denials and Next Actions
Unfortunately, there are times when a medical provider submits a bill multiple times and never makes any changes/corrections to a bill. Do not assume or expect the DOL insurance staff, nor the medical provider billing staff, to proactively resolve these discrepancies for you. Often, when a worker has more than one insurance provider, a billing department will choose the path of least resistance, and simply bill Medicare or your 3rd party insurance. I encourage workers to visit the front desk before or after each visit, to remind staff to “bill to the White Card”.
Or what is worse, is that after 2-3 months of trying to submit a bill, the provider refers the claim to a bill collector, and this is the first time you, the patient, hear about it. This is upsetting and frustrating. When this happens, contact the original billing provider, and confirm what and how they billed in the first place, determine whether the service was in fact related to your approved condition, (get the facts first), and then ask them to correct and resubmit the bill through the system. You can also go online through the DOL/CNSI billing portal to see most of what you need on this topic or contact a Resource Center for assistance. Again, the most common issue is that for one or more of your approved conditions, the associated ICD 10 codes were not listed on the original bill submission, or if there were exceptions, those exceptions could be explained in the notes for the bill.
Bill Coding versus Adding Conditions
The main issue is usually the billing process. If you contact your DOL Claims Examiner, they rarely will spend the time to investigate. If you are given the time to explain the medical situation and what you needed, a Claims Examiner most likely will advise you to submit a new claim for yet another new condition, or a consequential condition. In our experience, the billing issue can be resolved more quickly and effectively by working with the medical provider and billing staff/agent. You do NOT always need to file new claims for additional conditions.
The simplest way to minimize these billing issues is to be proactive with your medical providers. Ask them to always reference the original and approved ICD 10 for EVERYTHING your doctors believe is related to the approved medical condition, and where appropriate, add notes to explain linkage to other conditions/services. It is not always simple though. In some cases, where treatment for a previously approved condition has caused subsequent, formally diagnosed consequential conditions, it does make longer-term sense to go ahead and file for additional conditions.
Adding conditions that are related to or caused by previously approved conditions is a topic for another blog.
I am Al Frowiss from AtomicWorkers.com. We are an independent Advocate and Representative for current and former Energy Employee workers and their families.
In our practice, we strive to set appropriate expectations for our clients. Use of the ‘White Card” is the most important value a worker may receive from this program. Hopefully, this blog provides a basic level of understanding for how things work behind the scenes. If you would like to learn more about how AtomicWorkers can help, please contact us directly. We return calls and emails promptly.