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Ebilling Required for Workers’ Compensation
(source: Texas Medical Association)

The workers’ compensation system in Texas is finally adopting electronic billing and reimbursement. Physicians who treat workers’ compensation patients in Texas must be able to bill electronically by January 1, 2008 or qualify and file for an exemption waiver by October 31, 2007. This is a helpful guide for physicians to determine what action steps to take to meet the electronic billing requirements.

If you have read this far after seeing this piece is about workers’ compensation, then more than likely workers’ compensation patients are a part of your practice. The first logical step is to determine if you meet the criteria for a waiver from the requirements to bill electronically. Even if you meet the requirements for a waiver, there are certainly advantages to billing electronically, like a reduction in administrative burdens with electronic acknowledgements that bills were received. Other benefits include streamlined bill processing and a reduction in billing and coding errors.

For those physician offices that may not be required to bill electronically, you must qualify for an exemption by filing a waiver with the Texas Department of Insurance – Division of Workers’ Compensation (TDI/DWC). Waivers are available to qualifying entities based upon two justifications:

Small practice – physicians that employ ten or fewer employees and workers’ compensation accounts for less than 10% of their practice; and
Financial burden - physicians that can substantiate that implementing electronic billing presents an unreasonable financial burden.

The deadline for submitting a waiver request to the Texas Department of Insurance, Division of Workers’ Compensation (TDI) is October 31, 2007.

For those physicians who are required to bill electronically, physicians are responsible for establishing their own business relationships for e-billing. Whether you bill internally or externally with a billing service company, a contractual relationship must be established with an e-billing company for workers’ compensation claims. If your billing is done externally, you should ensure that your service company is prepared for e-billing for your workers’ compensation claims.

TDI/DWC will provide a comprehensive list of insurance carriers and federal employer identification numbers (FEINs) for insurance carriers. The FEINs can be used by physicians when submitting an electronic bill. TDI also will provide names and identification numbers for insurance carrier agents/clearinghouses provided by the insurance carriers.

Physician offices need to prepare for the requirements and deadlines of e-billing in worker’s compensation. Some of the administrative hassles and burdens that plague the workers’ compensation system will be reduced with electronic billing and reimbursement. With the proposed rules to increase the medical fee guidelines in workers’ compensation and the adoption of e-billing, delivering care to injured workers in the workers’ compensation may be improving. After all, it’s about time.

Quick guide to Texas eBilling

As mentioned above, assess if the e-billing regulations apply to your practice. If you treat Texas workers’ compensation patients, have less than 10 employees in your practice, and less than 10% of your revenue comes from workers’ compensation, then the rules most likely do not apply. However, you must file for a small practice waiver with TDI/DWC to be exempt from e-billing requirements.
Once you know if the e-bill rules apply, you need to assess your business needs and technical capabilities. Identify your major workers’ compensation payers and either contact them directly or refer to the TDI/DWC website, where all payers and their respective e-billing agents are posted. Additionally you need to know if your practice management system, clearinghouse, or billing service can comply with the Texas workers’ compensation e-bill requirements and how they can help you become compliant. Remember that the e-bill requirements not only include the submission of bill data, but also include the submission of supporting documentation electronically.
The use of an e-billing agent is allowed by the rules, but not required. E-billing agents often have a variety of tools to help you comply with the requirements and often represent multiple physicians and payers. Some agents manage only providers, some manage only payers, and some manage both. As you go about selecting an e-billing agent you may want to check the TDI/DWC website to see who manages the majority of payers that your practice bills. Call them and assess their capabilities and how they meet your needs.
E-billing agent services should include:
- Paper conversion capabilities – for the practice that is most or all paper today, or if your system cannot or will not produce electronic files for submission, having paper bills and documents converted into electronic data files is an option.
- Web portal services – including direct entry of a bill and supporting documents into web-based screens and/or uploading of bill files and document files directly from a PC. These tools often include online correction capabilities to ensure the billing meets the compliance guidelines, and automated bill to attachment pairing.
- Document submission – if you have a Document Management or Electronic Medical Record system, then sending electronic documentation will be facilitated. But, if you have not made that kind of investment, many e-billing agents can offer you capabilities that work with your present fax machine.
- Direct feeds- if a provider has enough volume for one or many carriers, it may make business sense to establish a direct feed of data from their systems to a specific carrier(s) or their eBilling agent(s). This is probably the most involved method of submission and volume will be the key driver for the economic decision to go this route.
Lastly, physician practices should develop an operational plan for e-billing. This could include educating your staff on the e-billing requirements, as well as making changes in your workflow to help you streamline the process.

Article Contributors with Contact Information:

Michael Reed, Texas Medical Association (www.texmed.org) E-Mail: michael.reed@texmed.org

Jeremiah Bentley, Texas Mutual Insurance Co. (www.texasmutual.com) E-Mail: jbentley@texasmutual.com

Texas Mutual Insurance Company is the state’s leading provider of workers’ compensation insurance. More than 46,000 Texas employers and their 831,000 employees count on us to be there for them every day.

Sherry Wilson, Jopari Solutions, Inc (www.jopari.com) E-Mail: sherry_wilson@jopari.com

Jopari supplies integrated e-billing compliance and payment solutions to workers' compensation industry payers and providers. For physician inquiries regarding e-billing services, please call (866) 269-0554.

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