Balance Billing Rules for Worker’s Compensation Cases
Unlocking work comp billing: Illinois fee schedule caps your payments. Exceptions for non-compensable injuries or partial payments mean you can use negotiated rates or the workers’ comp fee schedule for balancing billing.
If you’re having conversations with a patient and their attorney or the employer to determine exactly when you can balance bill in a work comp case, there are some really specific rules that you need to be aware of. First of all, you have to know that if you’ve received payment for services that you’ve rendered from an employer, from the employee from insurance, work comp insurance carrier, whatever the case might be, and the amount that you have received is equal to the Illinois established work comp fee schedule, then that is the maximum that you can collect for that service for that patient. So if you’ve received payments that equal that amount on that fee schedule, you cannot balance bill a patient for the remainder, much like a PPO arrangement, you have to write down that amount to that work comp fee schedule that has been established by law. But there are a couple of other cases where you can balance bill the patient.
First of all, if the injury is considered to be non-compensable, or it is not a workplace injury. Now, sometimes there’ll be a dispute and you can’t collect while that’s being disputed at the commission. But once everything is final, maybe the employer has said it’s non-compensable and the patient agrees, or it’s gone through the process and the Illinois Workers Compensation Commission has established that it is not compensable, or it’s not work-related. In either of those two cases, you can balance bill the patient. And what the law says is you need to build their health insurance first. And that, of course, is still if it is within that timely filing requirement that is dictated within your contract or within the policy that you have in those cases, then you can and should bill health insurance as long as it’s within those timeframes for those non-compensable injuries. Now after that, of course, then you would still be able to balance bill the patient.
Now an additional quandary comes in where it is a compensable case, but maybe the insurance company or the employer or whatever has said that services you performed are not medically necessary or they’re only paying a portion of your claim. In those cases, anytime where an employer or the insurer is paying a portion of the bill, the law changes the rules a little bit, and here’s what happens. You can only bill our balance bill the patient for the lesser of your fee schedule that you have billed in negotiated rate if you happen to negotiate a lower rate than that with a patient, which you know, we’ve we’ve covered that in a lot of our discount videos that we’ve discussed, or the third is this. The worker’s compensation fee schedule. In other words, never should you be billing. If the employer has paid a portion or the insurer has paid a portion of that medical bill. Never should you be billing higher than that Illinois-established worker’s compensation fee schedule.
So if it’s fully non-compensable, of course, tried to build health insurance and then balance both patient. If it is compensable and there’s been a portion that is paid in a portion that is not you still would be limited by that Illinois workers compensation fee schedule. You can’t build over that amount, nor can you build over what your standard fee schedule is for the services that you’re billing for. Hopefully, this information helps you out when you’re billing or balance billing or attempting to balance bill work comp cases. We’ll catch you next week.