| Winter 2009
Texas Mutual Earns High Marks
for Paying Providers Timely
Texas Mutual Insurance Company was recognized as a “high performer” in the Performance-Based Oversight (PBO) report issued by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) this fall.
The PBO report evaluates carriers’ timeliness in paying health care providers for their services, as well as submitting required data to the DWC and delivering income benefits to injured workers.
“Texas Mutual considers health care providers as partners in the workers’ compensation system,” said Mike Dileo, Texas Mutual senior vice president of claims. “They deliver quality care to Texas’ injured workers and help them get back on the job. We are committed to compensating them fairly, accurately and timely for their services.”
Texas Mutual needs your help to ensure a smooth billing process. Dileo encourages you to share these billing tips with your office staff.
Submit within 95 days
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) requires you to submit bills within 95 days of the date of service, per DWC Rule 133.20(b). You may correct and resubmit as a new bill an incomplete bill that has been returned by Texas Mutual. The corrected bill is subject to the 95-day rule.
Code correctly
Use the correct billing modifiers from the applicable DWC fee guideline in effect, per DWC Rule 133.20(c):
- GP / GO are not valid with rehab programs (97545, 97546, 97799-CP)
- 69 modifier is not valid and should not be billed
- Rehab programs should be billed with the applicable modifier to indicate which program was provided (WC, WH, CP, MR)
Practice the three D’s: document, document, document
Ensure that your documentation supports the level of service you bill for. DWC Rule 133.210(c) lists the required documentatin that must be submitted on:
- Two highest levels of evaluation and management codes
- Surgical services of more than $500
- Rehab programs (WC, WH, CP, MR)
- Itemized statement for hospital services
- Any procedure that does not have a defined maximum allowed reimbursement
Know when not to bill employers
Do not bill employers for charges an insurance carrier has reduced, denied or disputed, per DWC Rule 133.20(j)4. Mark bills “information only” if the employer chooses to pay them, per DWC Rule 133.20(j)2.
Complete required forms
Box 32 on the CMS-1500 is a required field for clean claim submissions, so make sure you complete it. Also, remember that DWC Rule 129.5(c) requires you to complete and sign Form DWC-73.
Have licensed providers submit their bills
DWC Rule 133.20 requires physician assistants, nurse practitioners and other licensed providers to submit their own bills. The DWC does not recognize physical therapy or occupational therapy assistants as licensed practitioners. Submit their bills under the licensed supervising provider. Documentation should reflect the appropriate licensed provider.
Bill units appropriately
For example, bill anesthesia with units that represent actual minutes of anesthesia time. Do not bill multiple units for codes that do not allow reimbursement more than once per day, such as 90801.
Get more information
For more information about billing, visit the Providers section at texasmutual.com.
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