When an employee is injured on the job, they need to file a claim with their employer’s workers’ comp insurance company to receive benefits. This is typically done through the Human Resources (HR) department. HR will facilitate the claim filing process and work with the insurance adjuster.
We take an intricate look at billing workers’ compensation through an HR department.
We will cover:
- Overview of workers’ compensation billing
- Steps for filing a claim
- Information needed for the claim
- Working with HR and insurance adjusters
- Receiving workers’ comp wage and medical benefits
- Appealing denied claims
- Tips for smooth billing process
Follow the steps outlined below to ensure you receive the workers’ compensation benefits you are entitled to if injured at work.
Overview of Workers’ Compensation Billing
Workers’ compensation functions as a type of injury insurance. When an employee gets hurt on the job, workers’ comp pays for their medical treatment and replaces part of their income if they miss work.
The employer or their insurance carrier handles paying out workers’ comp benefits. Employees should never be required to pay for their own medical care or lost wages for a work injury.
Medical providers will bill workers’ comp insurance directly. For lost wages, the employer will continue paying the employee’s salary but get reimbursed by submitting wage statements to the insurer.
It is illegal for employers to retaliate against employees for filing workers’ comp claims. Failing to provide workers’ comp insurance can result in fines or criminal charges for businesses.
Overall, the workers’ compensation billing process involves:
- Employee injury occurs at work
- Employee reports injury to employer
- Employer submits claim to workers’ comp insurer
- Insurer accepts claim and pays out medical and wage benefits
- Employer/insurance carrier submit documentation for reimbursement
Employees are responsible for promptly reporting injuries and working with HR/insurer to get benefits.
Steps for Filing a Workers’ Comp Claim
Follow these key steps when you suffer a workplace injury:
- Report the Injury Immediately
Report any work injury to your supervisor right away, no matter how minor it seems. There are strict time limits for reporting claims. Waiting to file a claim could cause problems getting your claim accepted. - Seek Medical Treatment
Get appropriate medical care for your injury, even if it doesn’t seem serious. Seeing a doctor creates a paper trail and medical documentation you’ll need for your claim. Employers are required to provide a medical panel of physicians. - Notify Human Resources
Contact your HR department about the injury. HR needs to be aware of the incident and can assist you with starting a claim. Provide details on how, when and where the injury occurred. - Complete Required Paperwork
There will be various forms you need to complete about the injury and your medical status. This includes an accident report, claim form, medical releases, and wage statements. HR will provide the correct claim packets. - Communicate with Insurance Adjuster
The insurance claims adjuster assigned to your claim will investigate the incident and determine compensability. Be responsive to the adjuster’s inquiries and share medical records when asked. - Track Your Medical Treatment
Document all doctor visits, tests, procedures, medications and expenses related to your injury. Save all medical bills, prescriptions, and records. You will need this to prove your injury and treatment costs. - Return to Work When Able
Notify HR when you are medically cleared to return to work after an injury. If you have permanent restrictions, your employer should accommodate you. Discuss options like modified duty with HR. - Consult an Attorney if Necessary
For severe or complex claims, it can help to discuss your case with a workers’ comp attorney. They can deal with insurers on your behalf and help you receive full benefits.
Complying with these steps ensures you promptly report the injury, seek proper medical care, cooperate with HR/insurer requests, and positioning yourself for the best outcome.
Information Needed for Your Claim
There is specific information HR and the insurance adjuster will need to process your workers’ comp claim.
Having these details readily available can speed up starting wage and medical payments:
- Date, time and location of the injury
- How the accident happened and what caused it
- Nature of the injury and body part(s) injured
- Names of any witnesses or individuals involved
- Name and contact for the treating physician(s)
- Dates of medical treatment and appointments
- List of medical tests, procedures, medications related to injury
- Medical records, bills, expenses for treatment thus far
- Impact on your ability to work including estimated return date
- Pay rate, missed days/hours if out of work, wage reimbursement amount
Providing thorough details and documentation enables the insurer to quickly determine compensability and begin paying your benefits.
Working with Human Resources and Insurance Adjusters
HR plays an integral role in managing the workers’ comp process for employees. They initiate claims, liaise with insurers, and help return injured staff to work.
HR’s responsibilities include:
- Maintaining records of injuries and illnesses
- Reporting incidents to insurer within 24 hours
- Monitoring claims and benefit payments
- Providing claim packets with required forms
- Communicating with insurers on the employee’s behalf
- Ensuring compliance with state workers’ comp regulations
- Facilitating modified or light duty arrangements
HR works closely with claims adjusters who determine if claims are accepted and manage ongoing benefits. Adjusters investigate claims, authorize treatment, and process payments.
Tips for working effectively with HR and adjusters:
- Ask HR any questions about the claims process
- Complete insurer forms fully and accurately
- Promptly provide medical records when requested
- Communicate about health updates that could impact benefits
- Follow physician recommendations for treatment plans
- Notify HR/insurer if issues arise with benefit payments
- Maintain detailed notes about claim communications
Developing a collaborative relationship with HR and adjusters streamlines the claims process and ensures you receive benefits owed in a timely manner.
Receiving Workers’ Compensation Wage and Medical Benefits
There are two main types of workers’ compensation benefits – wage replacement for lost income and coverage of medical treatment costs.
This is what you are entitled to:
Lost Wages
- After a short waiting period, you receive a portion of your wages tax-free while recovering
- Wage rate is based on your earnings in the weeks prior to injury
- Payments may be made biweekly or monthly until you can return to work
Medical Treatment
- All reasonable and necessary medical care related to the workplace injury is covered
- This includes hospitalizations, surgeries, medications, devices, therapies
- Mileage for visits, modifications for home/vehicle may also be included
- You should not see any bills – providers are paid directly by the insurer
- For serious injuries, benefits may extend for prolonged or lifetime care
Your HR and claims adjuster will explain benefit amounts, payment schedules, and duration you can expect to receive wage and medical benefits. Make sure you understand when payments start and how long they continue.
If issues arise with benefit amounts or denied payments, contact HR and insurer right away. You may need to submit appeals to get compensation corrected.
Appealing Denied Workers’ Compensation Claims
Sometimes workers’ comp claims get denied by insurers.
Common reasons include:
- Injury deemed not work-related
- Missed reporting deadlines
- Limited medical evidence linking injury to job
- Claim details called into question
- Pre-existing health conditions contributed
If your claim is denied, you have the right to appeal the decision. Reasons for appealing may include:
- Disagreement over whether injury arose from employment
- Circumstances prevented prompt reporting
- Insurer not considering all medical evidence
- Contesting claim investigation conclusions
- Pre-existing condition was aggravated by occupational duties
The appeals process involves:
- Filing a Written Appeal
Submit an appeal letter to the insurer outlining why their decision is incorrect and should be reversed. Include additional evidence to support your claim if available. - Insurer Reconsiders the Claim
The insurer will take a second look at the claim details, investigation, and medical records along with your appeal reasons. - Insurer Renders Decision
The insurer will either uphold the original claim denial or overturn it based on the appeal. Typically decisions are made within 30 days. - Hearing with Workers’ Comp Board
If claim is denied again, you can request a hearing with your state’s Workers’ Compensation Board. A hearing officer will consider both sides and make a binding decision.
Having an experienced workers’ comp attorney assist with appeals can increase chances of success. Do not give up if your claim is initially denied – going through the appeals process can get benefits reinstated.
Tips for a Smooth Workers’ Compensation Billing Process
Navigating workers’ compensation can be complex, but these tips will help the billing process go smoothly:
- Report all workplace injuries immediately, even if minor. Late reporting causes issues.
- Provide detailed incident/injury information upfront. Don’t leave anything out.
- Follow recommended treatment plans. Noncompliance hurts claims.
- Keep extensive records and copies of everything claim-related.
- Communicate regularly with HR and insurer about health updates, return to work status, and benefit questions.
- Complete all paperwork accurately and quickly. Forms establish benefits.
- Stay on top of medical bills. Verify they are being paid by insurer.
- Return to work as soon as medically able. Modifications can help ease transition.
- Comply with insurer requests for medical records, interviews, exams etc. Refusal seems suspicious.
- Don’t give generic or vague answers to questions. Thorough explanations help.
- Get representation if your claim is denied. Appeals reversal rates are higher with attorneys.
Summary
Suffering an on-the-job injury can be stressful. But understanding the workers’ compensation billing process, involving HR promptly, following proper protocols, communicating effectively, and thoroughly documenting your claim facilitates prompt payment for your lost wages and medical care. While every claim is unique, adhering to the steps and tips outlined above will enable you to navigate the system successfully and receive the maximum benefits you are entitled to under the law.
