How it differs from health insurance
The critical operational differences
1. Verify the claim is accepted before treating. A workers’ comp claim can be denied by the carrier — meaning the injury is not compensable. Care delivered on a denied claim may leave you unpaid, and billing the patient is complicated by state rules. 2. Authorization requirements are frequently strict, and vary by state and by treatment type. Many states require pre-authorization for specified services. 3. State-specific reporting is mandatory. Most states require injury reports, treatment plans, and work-status reports on prescribed forms and timelines. Non-submission can delay or prevent payment. 4. E-billing is mandated in a growing number of states, with prescribed formats and companion requirements. Confirm your state’s requirement and whether your clearinghouse supports it.Fee schedules
Most states set a workers’ comp fee schedule by statute or regulation. It is frequently more generous than commercial rates for the same services — which is why WC volume can be attractive despite the administrative burden. A minority of states use a different mechanism (usual and customary, or negotiated). Confirm your state’s approach.Enrollment
There is generally no network credentialing in the commercial sense. What you need is:- Registration with the state workers’ comp system where required
- Any carrier or network arrangement your state’s model uses
- E-billing setup where mandated
Getting paid
1
Confirm the claim number and carrier before the visit
2
Verify the claim is accepted and the injury is compensable
3
Obtain authorization for the planned treatment
4
Deliver care and complete state-required reporting on time
5
Bill per the state fee schedule, with required documentation attached
6
Appeal through the state board process if denied
Quirks worth knowing
- No patient responsibility — do not bill the patient
- Attorneys are frequently involved, and records requests are common
- Independent medical examinations may be ordered and can affect payment
- Payment can be slow, and AR aging expectations differ from commercial
- Paper checks are common — see Handle paper checks