Managing Department of Labor Workers’ Compensation claims, including benefit determination, presents unique challenges for healthcare providers. With strict federal regulations, extensive documentation requirements, and high denial rates, Department of Labor (DOL) claims can significantly impact a provider’s cash flow and operational efficiency. Healthcare organizations that fail to address these complexities risk falling into the RCM death spiral, characterized by growing backlogs, rising administrative costs, and missed revenue opportunities.

UHS offers specialized solutions to help providers navigate these challenges and improve their financial outcomes. In this blog, we’ll explore the most common issues in managing DOL claims, best practices for resolving them, and how UHS’s expertise can unlock cash flow efficiency.

The Challenges of DOL Claims Procedures

DOL claims are governed by programs like the Federal Employees’ Compensation Act (FECA) and the Longshore and Harbor Workers’ Compensation Act (LHWCA), each with unique requirements. The complexities of these programs often lead to delays, denials, and underpayments. Providers must adhere to each program’s internal rules and benefit plans to ensure claims are processed correctly. Here are some of the key challenges healthcare providers face:

• Strict Documentation Requirements: Providers must submit detailed medical evidence and injury verification to avoid denials.
• Timely Filing Deadlines: Missing filing deadlines can result in permanent revenue loss.
• Complex Payer Rules: Federal and state-specific fee schedules add to the complexity of managing these claims.

Following the correct claims procedure is essential to avoid unnecessary denials and delays.

DOL claims often have denial rates ranging from 10% to 20%, with reworking costs of $31 to $124 per claim (MGMA). Addressing these issues is critical to improving cash flow and financial stability.

Common Denial Reasons and How to Prevent Them

Effective DOL claims management, which involves establishing reasonable claims procedures, starts with understanding the most common reasons for denials and implementing preventative measures to reduce them.

Missing or Incorrect Information

Denial Cause: Missing OWCP numbers, incorrect diagnosis codes, or incomplete documentation.

Claimants should receive written notice if required information is missing or incorrect, and a claimant’s failure to provide the necessary documentation can result in denial.

Solution: Implement a pre-submission checklist to verify that all necessary information is accurate and complete before submitting a claim.

Authorization Issues

Denial Cause: Lack of prior authorization or discrepancies in authorization details. Some services require prior approval, and obtaining such prior approval is a plan condition receipt for certain claims. Failure to secure prior approval when required by the plan may result in claim denial.

Solution: Use the OWCP Web Portal to manage authorizations and ensure that all services are pre-approved before care is provided.

Duplicate Claims

Denial Cause: Claims submitted multiple times due to processing errors.

Solution: Utilize UHS’s automated tools to track claims and avoid duplicate submissions.

UHS’s DOL Claims Workflow

Unified Health Services offers a proven workflow for managing DOL claims efficiently, from initial submission to denial resolution.

Step 1: Pre-Submission Checks

• Verify patient details, OWCP numbers, and documentation.
• Ensure all CPT/HCPCS codes are accurate and match the authorization.

Step 2: Claim Submission

• Submit claims through the OWCP portal.
• Use tools like SmeadLink to save confirmation numbers and documentation.

Step 3: Denial Management

• Identify denial reasons using Claim Adjustment Reason Codes (CARCs).
• Address common issues such as missing documentation or incorrect codes.
• Submit appeals using the Bill Adjustment Request Form (OWCP-BL-ADJ) or Fee Schedule Appeal Request Form (OWCP-FSA).

Step 4: Ongoing Monitoring and Reporting

• Track claim status and denial trends using real-time analytics.
• Conduct monthly reviews to identify recurring issues and improve processes.

Real-World Impact: UHS’s Success with DOL Claims

A large health system partnered with UHS to optimize their DOL claims management process. The results were significant:

• Denial Rate Reduction: From 15% to under 2%.
• Increased Collections: An additional $597,000 per 1,000 claims.
• Faster Payments: Days in AR reduced to 33 days.

By implementing UHS’s Day 1 and Day 30+ services, the health system recovered millions in lost revenue and reduced administrative burden.

Best Practices for Managing DOL Claims

To maximize cash flow efficiency, healthcare providers should adopt the following best practices:

Prevent Denials Before They Happen

• Use automated tools to flag potential errors before claims are submitted.
• Verify patient eligibility and authorization details in advance.

Standardize Workflows for Denial Resolution

• Create standardized templates for appeal letters and denial explanations.
• Use the OWCP Web Portal to track and manage denials.

Continuously Monitor and Improve

• Regularly review denial reports to identify patterns.
• Adjust workflows based on data insights to prevent future issues.

Why Partner with UHS?

Unified Health Services brings over 27 years of experience in managing complex claims, including those governed by the Department of Labor. Here’s what sets UHS apart:

• Expertise in Federal Programs: Specialized knowledge of FECA, LHWCA, and other federal programs.
• Technology-Driven Solutions: Automated tools that streamline claim submission and denial management.
• Proven Results: Reduced denial rates, faster payments, and improved cash flow.

Managing DOL claims and filing benefit claims doesn’t have to be a daunting task. By partnering with Unified Health Services, healthcare providers can streamline their claims processes, reduce denial rates, and unlock significant cash flow improvements. With the right tools, workflows, and expertise, your organization can achieve financial stability and focus on delivering high-quality patient care.

Ready to improve your DOL claims management? Contact Unified Health Services today to learn more about our specialized solutions for managing complex claims efficiently.