Work Comp and PI Basics

Personal Injury

Personal Injury: any type of injury received from a slip, fall or other types of accidents involving any type of vehicle, excluding work-related incidents.

The physician should always begin with a good history to determine causal effect of the injury. Without causal effect, the practitioner will have a difficult time determining the type of case that it is.

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With PI, it is imperative to obtain certain information that will assist you in receiving reimbursement for services rendered.

Accident/motorist report: this is what all drivers involved will received from the law enforcer. The Illinois State trooper may only provide a report number and a print out of the defendant.Within this report, one will find:

• Plaintiff’s name and address
• Defendant’s name and address
• Insurance carrier information:
  • the policy number
  • Who struck whom (usually considered Unit 1)
  • Who was struck (usually considered Unit 2)
• Insurance carrier information:
• Defendant
  • Adjuster’s name
  • Address and telephone number
  • Claim number
• Plaintiff
  • MedPay
  • Adjuster’s name
  • Address and telephone number
  • Claim number
  • Healthcare
• Any and all medical records, including the emergency room
• Attorney name (if any)

This information will provide the appropriate info to file a lien that complies with the Health Care Services Lien Act. The lien shall include a written notice containing the name and address of the injured person, the date of the injury, the name and address of the health care professional or health care provider, and the name of the party alleged to be liable to make compensation to the injured person for the injuries received. The lien notice shall be served on both the injured person and the party against whom the claim or right of action exists. Service shall be made by registered or certified mail or in person.

Workers’ Compensation

Workers’ Compensation: any injury resulting during the course of employment on the property of the employer or injuries resulting from duties performed off-site due to direct instructions of the employer.

The key in WC is direct causal connection and the injury must have happened within the course of employment. Lack of either will cause denial of the claim.

The employee must file a First Report within 45 days of the incident, as the Act is currently written.

Even though the employer may send the employee to the company doctor, the employee has the right to see no more than 2 physicians, which include referrals, of his or her choice.

The practitioner must acquire the following information:

• Employer name and address
• WC insurance carrier
• Adjustor name
• Address and telephone number
• Claim number

Once obtaining the appropriate billing information, the physician must submit the initial report with outcomes assessment for proper payment and subsequent bills (CMS 1500 forms) with attached notes to follow.

Documentation

If you find that you still have difficulty in receiving reimbursements, the next step is to check your documentation. Documentation must contain outcomes. If outcomes are not present, your check will not be there either. Document, document, document. This work is what allows us to receive reimbursements for services that have been properly rendered. If you feel that you lack in documentation, don’t fret. There are many of us who could always use a refresher. May I suggest the reader contacting the Illinois Chiropractic Society at (217) 525-1200 and register for the next documentation course.