This article is part of a series on the top reasons why insurance carriers object to a workers’ compensation report and return it to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.
You’re at the clinic and you receive a fax or a letter from an insurance carrier related to an impairment PR-4 visit with a workers’ comp patient
Payment for the visit? Not quite.
It’s an objection to your workers’ compensation report that you submitted for billing. The gist of the insurance carrier’s letter: there was something wrong with the visit note that was submitted with the bill. You’ll need to revise the report and submit it for billing again.
If you work in a medical clinic, then you may have had this experience before. Often, these letters do not point out the specific issues about the visit note.
This article series describes a few common reasons why a claims adjuster will not accept a workers’ compensation report.
Reason #1: Incomplete History of Symptoms
All workers’ compensation reports, including impairment PR-4 reports should include a full update on the injury’s symptoms.
- Symptom Quality – If the injury causes the patient pain, what type of pain is it? Burning? Aching? Has the symptom quality changed since the last time the provider saw the patient?
- Symptom Frequency – Do the symptoms occur every day? Every hour? Every minute? Has the frequency changed?
- Symptom Intensity – How bad are the symptoms, on a scale of 1 to 10? Is that an improvement from the previous visit, or not?
- Exacerbation – What activities or treatments exacerbate the symptoms by making them worse?
- Alleviation – What activities or treatments alleviate the symptoms? If standing up and taking Tylenol relieves the symptoms, then that should be in the report.
- Medication: Side Effects – Are there any side effects from medications that are being taken for the symptoms, or that impact the symptoms? Remission of symptoms – do the medications result in the alleviation of all pain and symptoms?
Including these details in a report may seem obvious to many providers. There’s even a box for these details in the “Subjective Complaints” section of the Doctor’s First report and Physician’s Progress Report (PR-2), and “Patient’s Complaints” section on the Permanent and Stationary (PR-4) report.
(See the images at the end of this post. If these sections of your clinic’s workers’ comp reports do not contain a robust update and description of the injury’s status, then you might have run into some trouble.)
However, the instructions for getting a complete update on the injury status isn’t explicitly spelled out for the provider. As a result, a hurried or inexperienced provider might miss a detail (or three).
But if any of these details are missing from a report, it may be considered incomplete, and sent back to the clinic from the insurance carrier or denied for requested treatment or services. This results in delay, frustration, and additional resources to update the report, republish and re-submit.
The completion of these small, but crucial details could mean the difference between swift payment and authorization of treatments, versus a drawn out process between the clinic and the insurance carrier.
Check back soon for the #2 reason why insurance carriers may object to a workers’ comp impairment PR-4 report.
The Subjective Complaints section in the Doctor’s First (5021) report:
The Subjective Complaints section in the PR-2 report:
The Patient’s Complaints section in the PR-4 report: