Austin Medical Times
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Legal Matters Who Is Going to Cover Covid Hospitalizations – Commercial Health Plans or Workers’ Compensation
By C. Ryan Morgan, J.D. Tish R. Pickett, J.D. Polsinelli, PC
C
ommercial health plans are delaying and even denying reimbursement for COVID-19 hospitalizations — especially high-dollar inpatient stays. Plans are attempting to defer these claims to workers’ compensation on the health plans’ assertion that COVID-19 is a work-related illness. Some hospitals defer to health plans, as it relates to these types of claims, because it is plausible that patients could have contracted COVID-19 at work and because workers’ compensation is typically primary for coordination of benefits purposes. But workers’ compensation is notoriously complex, and hospitals may not understand the nuances of the program
enough to know when it is appropriate to challenge this type of health plan denial. Failing to appeal these denials may impact hospital reimbursement, as well as a hospital’s accounts receivable days, known as “AR days,” depending on the number of COVID hospitalizations and the corresponding amount in open balances. A. Demystifying Workers’ Compensation With a Brief Overview It is important to have a general understanding of workers’ compensation coverage. Workers’ compensation is a state-mandated insurance program that protects employers and employees from financial loss when employees suffer job-related injuries and illnesses. Virtually all employers, even small employers, must maintain workers’ compensation coverage. If an employee suffers an occupational injury or illness, an employer through its workers’ compensation carrier may provide missed wage replacement, temporary and permanent disability, death benefits, and supplemental benefits. But one
of the basic benefits in all states is medical and hospital benefits. Each state regulates workers’ compensation coverage differently, which is a critical factor with respect to COVID-19 and whether a health plan may delay or deny payment. In some states, employer premiums for workers’ compensation policies are experience-rated, meaning that employers that file more claims pay more in premium. B. States’ Response to Classifying COVID-19 as an Occupational Illness When it comes to COVID-19 as an occupational illness, states have responded differently. On one hand, 17 states and Puerto Rico have extended workers’ compensation coverage to include COVID-19 as a work-related illness. Within this group of states, there are varying degrees of coverage. The majority of these states have established COVID-19 workers’ compensability presumptions for various types of workers. In these states, if a designated worker contracts COVID-19,
it is generally presumed that the worker acquired the virus during the course of employment thus eligible for workers’ compensation, including medical and hospital benefits. But employers can dispute this presumption and produce evidence to the contrary, if done so within a certain amount of time under state law. Hospitals are often left out of this decision-making process, which is unfortunate because hospitals may have additional information about where the worker contracted COVID-19. On the other hand, some states still consider COVID-19 an “ordinary disease of life,” similar to a cold or the flu, which means the virus is not covered by workers’ compensation. Still other states have taken no action to clarify whether COVID-19 hospitalizations and treatments should or should not be covered by workers’ compensation. Workers’ compensation see Legal Matters...page 14
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austinmedtimes.com
April 2021
