Saturday, May 11, 2013, 10:44 PM - Medical treatment under WCJudges and attorneys know it as a frequent scenario.
An injured worker, frustrated with the delays and treatment denials in the system, simply wishes to cash out their case. As part of a buyout they usually take a negotiated amount of money in exchange for releasing the insurer from liability for future medical treatment.
Perhaps the worker has other coverage that can be relied upon to fund treatment.
But maybe not.
Workers who have employer sponsored group health coverage or private coverage administered by companies such as Blue Cross or Blue Shield may find that their treatment is denied under the terms of the policy if the policy excludes payment for workers' comp related conditions.
What about workers who have no insurance or whose insurance will not cover workers' comp? Once they settle their cases, how do they fare?
Some of those workers may be eligible for Medicare, so they are expected under Medicare's rules to "protect Medicare's interest" by using an allocated portion of their settlement (a Medicare Set Aside) to cover medical costs before Medicare will willingly kick in.
Others will use their group or individual medical insurance anyway, despite exclusionary language, hoping that their usage of treatment resources caused by a work injury is not flagged by the insurer. Some will seek treatment at the VA or public clinics or county hospitals. Some may receive "charity care".
If there is any research on how workers who settle cases access treatment resources, I'm not aware of such studies.
Perhaps the Affordable Care Act/Obamacare will affect all of this. But for now it's not clear how many injured workers end up having to pay for treatment "out of pocket" after cases are settled.
But I'm sure there are some who do.
I was thinking about those workers as I noted that the Centers for Medicare and Medicaid Services has now released a study of hospital pricing. The study documents hospital-specific charge data on the 100 most frequently billed discharges from 3,000 U.S. hospitals (a link to the study is noted below).
The study documents that there is a huge range of billed charges from hospitals for the same procedure.
Insurers may get discounts. But if you are an uninsured injured worker without insurance, you may be charged the "rack rate" just as you would be if you walked up to a hotel and booked a room without a discounted reservation.
For example, a joint replacement may on average be billed at $83,538 at California Pacific Medical Center in San Francisco and $110,305 at St. Francis Memorial in San Francisco, just a couple of miles across the city. The same procedure at a local Kaiser was on average billed at less than half the cost.
Where injured workers have settled their cases and later found themselves without coverage, have they done comparison shopping?
Perhaps. I have personally represented several workers who settled their cases and used the funds to seek medical treatment in India or Thailand at a lower cost. Undoubtedly some immigrant workers from Mexico return there to get treatment.
But for workers who need to treat in the USA, obtaining such data has been hard until now.
For those workers who have settled their cases and are without other viable coverage, the CMS data may be helpful in choosing where to have elective treatments performed.
Here is a link to the CMS site where data can be obtained on charging practices of specific hospitals (the site has a search function to search for the hospital of your choice)
Here is another link to the CMS study:
http://www.cms.gov/Research-Statistics- ... index.html
Here is a link to a New York Times analysis of the study:
http://www.nytimes.com/2013/05/08/busin ... shows.html
Wednesday, May 8, 2013, 10:51 PM - Political developmentsThey call that a knee.
You can decide for yourself. But brace yourself. It's not a pretty picture.
I'm talking about the photo of Reggie Williams' knee.
The former football star is featured in a Sports Illustrated article about AB 1309, the bill which would limit the ability of professional athletes (including those in the minor leagues) to file California workers' comp claims.
Here's a link to the article:
http://sportsillustrated.cnn.com/nfl/ne ... index.html
As the author notes:
"It's possible that AB 1309 could be passed in a weaker form. For instance, the sides could grandfather in some current claimants so they maintain their existing benefits, or phase out their benefits gradually instead of abruptly terminating their cases. The ultimate irony remains that if the bill passes as currently written, Williams and other athletes would have to turn to government assistance in covering their medical costs. In that case, taxpayers would be the ones fitting the medical bills."
Read More: http://sportsillustrated.cnn.com/nfl/ne ... z2Slwmwg7e
Stay tuned. I'll continue to cover the controversy generated by AB 1309.
Monday, April 29, 2013, 10:40 PM - Political developmentsHere's a project for Christine Baker and Kathy Zalewski:
Clean up the unconscionable backlog of panel QME requests. The QME panel backlog as of mid 2012 had been whittled down to around 30 days under the leadership of former DWC Administrative Director Rosa Moran.
Thanks to the reporting of Greg Jones in Workcompcentral.com, we now know that the DWC has admitted that the backlog has grown by a factor of 5 times in less than one year!
Since mid 2012 the backlog has grown to 5 months according to a statement quoted by Jones from DWC spokeswoman Erika Monterroza.
Jones' article notes that Monterroza responded to an e-mail inquiry as follows:
"The subsequent delay in issuance of panels occurred after overtime and
student assistant work was no longer available".
Monterroza also noted that
"The current backlog for represented cases is back to November 2012".
In plain English, this means that the DWC is just now dealing with requests for QME panels in represented cases that were made around Thanksgiving.
In a normal private sector organization heads would roll or an emergency action plan would be put into place to rectify the problem.
But so far there is little indication that this is on the radar for leadership at the DIR and DWC.
It's not just workers and applicant attorneys who are disturbed by the delays. Insurers have reserves that are tied up as claims can't be resolved.
Self-insureds can't move files.
In some cases treatment costs may increase since workers in denied cases that are later accepted are able to treat out of network during the denial. Periods of temporary disability may be longer because a QME eval is delayed. The longer those claims are open the more likely that compensable consequence injuries are raised.
Some employers and insurers will simply not use AMEs. For example, a Safeway adjuster told me last week that their claims people have been told not to agree to AMEs.
But with the wait for panels getting steadily longer, those files are going to be lingering longer.
This is a project for CHSWC:
Do a study on why the DWC seems to have trouble issuing panels in a timely fashion.
And while you're at it, take a look at whether the division is adequately staffing the unit that will determine whether IMR requests are ripe for determination by Maximus.
Recently, Dr. Rupali Das of the Medical Unit was noted as saying that the DWC plans to publish some IMR decisions. It would appear that the DWC is taking on more projects at a time that it is mishandling other fundamental ones.
Sunday, April 28, 2013, 10:00 PM - Political developmentsWorkers' comp has been part of a grand bargain for many decades.
Workers generally gave up the right to seek redress by filing tort lawsuits against employers. Instead, workers' comp law provided a structured level of benefits to injured workers in lieu of having to prove fault in a court of law.
Workers' comp became a part of the social safety net, delivering medical treatment and some indemnity benefits to injured workers. As we know in California, that's a multi-billion dollar industry with its own set of stakeholder players who periodically instigate reform attempts in an effort to reallocate costs and their shares.
Then along came other trends.
Carve outs, where some employers and unions could set some of their own procedural rules.
California is now struggling with how it should deal with claims by athletes who file claims here, some of whom have very minimal connections to California.
How that is resolved could have bearing on how California deals with other interstate employees.
And now, in some other states such as Texas and Oklahoma, there are laws that would allow employers to opt out of workers' comp entirely.
Meanwhile, the long term effects of the Affordable Care Act are starting to roil America's health care system. Anyone who is paying even slight attention is likely to notice the steady stream of articles noting the concerns that are developing about how the ACA rollout is going. Perhaps those difficulties are due to the complexity of the law itself, GOP opposition, or problematic execution by the Obama Administration, or all of those reasons.
In any event, some observers are predicting large increases in healthcare costs, delays in implementation, confusion of small businesses and individuals, and a political train wreck.
If the ACA was to fail will there then be momentum for a single payer system ? A system that offers 24 hour care? There are already many advocates for that type of system.
If so, we could be looking at another very basic change in workers' comp in coming years.
The point is that there is nothing inherently sacred about the comp system.
It's always ripe for re-engineering.
We live in a time when the notion of entitlements is coming under scrutiny.
There's more focus on tax reform, immigration reform, public employee pensions, Social Security and Medicare. But you can bet on it that workers' comp will continue to evolve along with other publicly mandated and administered programs.
Here's a link to a provocative article by The Washington Post columnist Robert Samuelson, "The Twilight of Entitlement":
http://www.realclearpolitics.com/articl ... 18152.html
Wednesday, April 24, 2013, 11:03 PM - Political developmentsThe debate about how California should deal with claimed injuries of professional athletes continues to heat up.
Today AB 1309 survived a vote in the Assembly Insurance committee.
Most Democrats on the committee joined with Republican supporters.
Voting to move the bill as is were Democrats Susan Bonilla, Ian Calderon, Jim Frazier, Holly Mitchell, Ken Cooley, Norma Torres and committee chair Henry Perea.
Here is a link to an analysis of AB 1309, including a list of supporting and opposing organizations:
http://leginfo.ca.gov/pub/13-14/bill/as ... _comm.html
Here is a link to the current version of the bill:
http://leginfo.ca.gov/pub/13-14/bill/as ... sm_v98.pdf
This is not the end of the story, however. Negotiations about bill language will continue, and it is still not clear how the bill will fare in the California Senate.