Successful Workers' Compensation Adjudication

Successful Workers' Compensation Adjudication

Parallon's number one priority in managing your workers' compensation claims is to reduce your cost of handling highly specialized, complex accounts.

Historically, up to 12% of workers' comp claims are underpaid. That's why it's important to outsource your workers' compensation accounts so you can focus internal resources on your core competencies and other streams of A/R instead of spending a disproportionate amount of time keeping up with denials management, payment auditing and appeals.   


What You Can Expect When Outsourcing

When evaluating a trusted partnership, the most common attributes for success include:

-Placement of encounters day-one

-Electronic placement of encounters

-Vendor ability to pass files back to the healthcare system for notes, documents and close and return processes

-Supplying minimally weekly, but preferably daily, files for placements and transactions

-Minimum of monthly, but preferably weekly, reconciliation files

-If EPIC is your HIS, the establishment of billing indicators to remove manual work and automate workflows using the systems maximum capability

-Providing the vendor with electronic access to obtain medical records, correspondence, EOBs and other appropriate needed documentation. 

-Monthly operating reviews and frequent dialogue on operating performance

-Opportunities for continued improvement on identifying workers' compensation claims upfront


Workers' Comp KPIs to Report on

At Parallon, our primary financial measurements are collection percentage and days to resolution. We also track underpayments and underpayment recovery percentage.

Your workers' compensation partner should be providing you with financial reports and operating metrics so you have a strong sense of control and knowledge on the individual account status.

KPIs and reporting that you should receive on a monthly basis include:


Information on all events during the reporting period regardless of claim referral month

Recovery Regression Analysis

-Total cash collected

-% of cash collected against total referrals

-Claims remaining open and closed

-Batch tracking reports


Status and recovery stage of all active claims:

-Claims forwarded to a payer

-Claims pending receipt of additional information

-Accounts needing supporting documents - i.e. medical records or purchase order

- Timeliness of response from provider in terms of coding updates, medical records (if not available through the HIS system (i.e. physical therapy records), etc.

- Claims which a lien have been processed


Accounts that need additional support retrieving documentation - i.e. missing medical records, EOBs or purchase orders for implants which can provide additional reimbursement


Your vendor should also be monitoring quality and compliance to ensure the highest level of service standards are met.


Quality Assurance

During the resolution phase and before claims are returned back, quality assurance should be performed to audit how claims are being processed. Your vendor should be focusing on:


Were your requirements met and policies followed?


Was the account worked in a timely manner?

Appropriate reimbursement

Was the appropriate reimbursement achieved?

Proper and prompt initial encounter processing

Did the claim representative take the necessary steps to create a clean claim?

Quality of encounter documentation

Are the steps taken easily followed?

Research tools

Did the claim representative use all information, tools and resources available to them?


Is the claim resolved within optimal cycle time and with appropriate reimbursement?

Denied as not workers’ comp

Does your vendor have the ability and expertise to process non-workers’ compensation claims to commercial Health Insurance carriers with a valid workers’ comp denial?

Proper partnership support

Does your vendor have a nurse case manager available to review utilization, medical necessity and coding denials, and make recommendations to the health system for changes?


When you’re evaluating outsourcing your workers' compensation claims, ensure you partner with a revenue cycle vendor that focuses on results, continuous process improvement and quality assurance to ensure compliance and consistent performance. Assure they are experts in this field, but not separate in their partnership with you. 

Want to learn more about how we accelerate claim resolutions and cash flow? Contact our workers' compensation experts.