Introduction

     Federal Worker’s Compensation claims, paid through the U.S. Department of Labor (USDL), have been a long-term problem for Alaska medical providers. The difficulties encountered when dealing with this patient population have led many offices to refuse to accept USDL patients, except under very specific circumstances. These difficulties include delays in payment, frequent rebillings, low reimbursement rates, inability to get telephone assistance, and multiple lengthy and redundant forms.  Physicians want to be able to treat sick and injured patients, and they have become increasingly dissatisfied with the Federal Worker’s Compensation guidelines, which have made caring for these injured workers so very difficult.

     Injured Federal workers are given a variety of forms and instructed to have their physician complete them. These forms are time-consuming for the physician to fill out, and most of the information requested from the physician is already found in the standard medical office dictation that describes a worker’s compensation patient visit. Examples of these forms may be found at the back of this document, pages A-1 through A-14. One of the best ways to control health care costs in a physician’s office is to keep the physician productive. In the time required to complete one of these Federal Forms, the physician could have seen an additional patient.

     In 1991 Anchorage Fracture & Orthopedic Clinic (AFOC) worked out an arrangement with Dr. Robert Reynolds, at the USDL office in Seattle, whereby we would see USDL patients, but not complete their lengthy forms. We would use our standard billing forms and work releases, submitted with our chart notes, which answer all the questions in their forms. This arrangement was part of a larger agreement for AFOC to agree to a 90-day trial of seeing Federal Worker’s Compensation patients. If we were the first physicians to examine the patient, we would complete the Form CA-16 (example on page A-1), which is the report of initial injury. (Correspondence from and regarding Dr. Reynolds is included on Page B-1 and B-2.) Our office continues to complete Form CA-16 today, although we still do not fill out the other forms.

     At the time the 90-day trial was set up, there were no orthopedic surgeons in the Anchorage area who were willing to see USDL patients, due to the cumbersome paperwork, and an undercover sting operation by the U.S. Department of Labor in the Fall of 1987 through the Spring of 1988. In this sting operation two agents were sent to various physician offices posing as postal worker employees with work-related injuries, with the intent of tricking the doctor into granting unnecessary time off from work. The agents wore wires, and recorded the office visits. A news article from the Washington State Orthopedic Society newsletter from Spring, 1989 is included on pages B-3 and B-4, and gives the complete story on this sting operation. It should be noted that the Anchorage orthopedist featured in the story was a member of our group at the time. Following the sting operation our clinic, as well as most orthopedists in Anchorage, refused to see any USDL patients until the 90-day trial was attempted in 1991. USDL patients needing care had to be sent to Seattle.

     In the past three years the low reimbursement rates and amount of staff time involved to obtain payment for services have led our clinic to again stop accepting appointments from USDL patients, scheduling them on a self-pay basis only. We are happy to see the patient, but we do not want to take on the headaches associated with billing USDL and the process of returning the patient back to work. Our doctors may individually choose to accept a patient with their USDL coverage if they are contacted directly by another physician.

The only exception to this rule is when we are the assigned orthopedic trauma call physicians for the city, covering the hospital emergency rooms. In this situation we accept any and all patients, along with whatever insurance coverage they have, if they are either seen by our physician in the emergency room, or referred to our office for follow-up after treatment in the E.R. by any E.R. physician.

Details of Problems Experienced with USDL Patients

Low Fee Schedules

     The fee schedule from which the USDL pays is extremely low, as shown in the examples, which follow. Details of these actual patient charges and payments are found in the appendix, as referenced by page number below. Detailed is the Surgical CPT code, a brief description of the procedure, our charge for that particular code, USDL’s actual payment, and the amount written off. As demonstrated, the amount written off is frequently higher than the amount actually paid for the service.  Also included are the maximum allowed amounts for each procedure per the State of Alaska Worker’s Compensation fee schedule, and the average commercial insurance allowable for the area, based on the Medicode Fee Analyzers for our specific area (this schedule also shows the average charge for our geographic locale).

2. Delays in obtaining Case Numbers

     Past experience and the information available to us lead us to conclude that it takes at least 30 to 45 days for a Case Number to be issued to an injured Federal worker. Since a claim cannot be submitted without a Case Number, there is a delay in the billing if the patient has either not yet received a number, or not given it to the physician. Once the number has been given to the patient, they may not think to call the physician and provide them with that information, perhaps because they are not informed of what a critical piece of information it is.

     There is no way to bill a claim to the USDL without a Case Number. Billings sent without a Case Number are returned immediately with a denial stating there is no valid claim number on file. The provider of service has no way of knowing if there is actually no Case Number on file, or if the provider just does not have the information. The USDL payment office is either unable or unwilling to do a name search to determine if there is a Case Number in existence for that patient.

Rebilling of claims

     Rebilling of medical claims is time-consuming and is frequently necessary before payment can be obtained from USDL. As mentioned above, the claim may be returned for no Case Number.  However, many times we have had a Case Number and had it written on the bill, only to have the claim rejected for no claim number! It appears that it is possible for a claim number to exist in one part of the USDL computer without being cross-referenced to the claim payment system.

     Denials are also received due to the diagnosis on the medical billing not matching the diagnosis attached to the Case Number (see page F-19). Denials are frequently received which say "Billed services not related to the accepted conditions in this claim." If the claim is rebilled three to four times, without any changes, it will eventually get paid, as the claim number finally gets updated with the correct medical information. An example of this is described in the situation detailed below.

     There seems to be poor communication between Federal employers and employees and the USDL. I question whether this is due to employers and employees not being properly instructed in the entire process, or whether the process itself is so complicated that it is difficult for even the most diligent, well-trained person to complete it correctly.

     An example of this is the medical claim beginning on page F-1. In this claim the employer authorized the work-related condition (see page F-6), and the USDL issued paperwork with a claim number, but it still took eight months from the date of surgery, plus hours of staff time, for our office to receive payment for the surgery charges. This patient, who is an FBI employee, was injured on April 13, 1996, and was seen in the emergency room in Fort Smith, Arkansas. He consulted in our office on August 5, 1996, but did not indicate that this was a work-related condition. The patient completed the appropriate USDL forms on August 12, 1996 (see page F-3), and notified our office on August 13, 1996 that this was a work-related condition, and that we were to send the bills directly to his employer at the FBI office in Anchorage. With our knowledge of the difficulties in dealing with the USDL this seemed like an effective alternative for handling the billing. We received notification from USDL dated September 23, 1996 that the claim had been accepted, and a case number assigned (page F-5).

     Meanwhile the patient had required surgery for his back, which was performed on August 27.   Although authorization for surgery had not yet been received from USDL, the patient’s employer assured us that, as long as our physician felt the surgery was medically necessary and needed to be done without delay, we should proceed, and authorization could be obtained retroactively. This began a series of denials and rebillings. We were working with the local FBI office, who was assuring us that this was a valid claim and would be paid, but all the while we were receiving denials and rejections on the surgery claim from the USDL. Although they were paying the physical therapy and doctor visits for the patient’s back condition, they were denying the patient’s back surgery because it was not related to the condition accepted for his claim (see denial notice on page F-19).

     Complete documentation of this situation is found on pages F-1 through F-21. These types of machinations are not unusual when working with USDL, and demonstrate the amount of staff and physician time required in resolving an unpaid claim. It always appears that the right hand does not know what the left hand is doing at the USDL, and in this particular example resulted in the major part of our charges not being paid until April 21, 1997, eight months after the services were performed.  We received the check on April 29. Payment on a $4,100 charge was only $2,102, 45.6% of the Alaska Worker’s Comp allowable, and 49.3% of the commercial indemnity allowable for our area.

Automated telephone system

     When calling the USDL it is not possible to call and speak to a person. The caller punches numbers and leaves a message. The message process that must be followed to get information or leave a message for a call back is very long, and there is no way to bypass the message (such as pushing "0" for an operator) and reach a person. Recent experience has shown an improvement in the timeliness of call-backs, but the process is frustrating, particularly when a doctor is waiting for information, or a patient is in the office, waiting for help.

     At one point we had a contact in the USDL office who we could reach directly, and who was very helpful, but she no longer works there.

Conclusion

     In conclusion, in order to adequately assist injured federal workers, while making it a worthwhile business decision to treat them, we need the following:

     Higher fee schedules, which should have geographic adjustments to account for different price ranges in various parts of the country (similar to Medicare’s GPCIs), and which match, or nearly match, the state Worker’s Compensation fee schedules.

     Easier access to the claim payment office.

     Less paperwork for the patient, employer and physician to complete, which would speed up the entire process and make it less prone to error.

     Overall simplification of the process, by reducing the length and number of forms, the authorization process whereby a condition is accepted as work-related, and improvement in access to the claims office. There may be states with Worker’s Compensation systems which work well, and might be used as a model.

     Approximately 20% of the patients in our clinic are Worker’s Compensation (mostly state of Alaska worker’s comp), 17% are Medicare, 5% are Medicaid, and about 5% are self-pay. Obviously we are accustomed to State and Federal regulations and compliance issues, and are also willing to treat patients who may not have top-notch insurance benefits. Our physicians want to be able to treat sick and injured patients, but the USDL rules make it virtually impossible to do so.

     The Federal Government is the largest employer in Alaska (see page G-1 and G-2), and many of our friends and relatives work for them. However, due to the combination of low reimbursement rates, the past history in dealing with the OWC, and the difficulties in receiving payment, treating USDL patients makes poor business and medical sense.
 

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