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Showing posts with label TPA. Show all posts
Showing posts with label TPA. Show all posts

Wednesday, August 27, 2014

The Word Didn't Get There

Problems with the national workers' compensation system are addressed in today guest post authored by David DePaola and shared from http://daviddepaolo.blogspot.com/
Then I get an email from a former claims professional turned auditor that completely deflates my enthusiasm and makes me angry.
The emailer has been in the process of auditing some cases on behalf of an insurance carrier whose cases are administered by a Third Party Administrator.
This is a pretty typical arrangement. Carriers are very good at "writing the paper" and all the processes involved from brokerage administration to determining the risk (underwriting) and marketing. Then the job of actually handling the claims gets outsourced to specialized companies: TPAs.
The auditor writes she's appalled; outraged at the lack of any sense of urgency, the lack of responsiveness to defense attorneys, not to mention applicant's attorneys.
She's astounded at the failure to pay temporary total disability, the failure to advance permanent disability a year after the Agreed Medical Examiner's findings are undisputed to a person who's getting $500.00 a month from Social Security.
She's offended that the TPA lets the defense attorneys handle the files, lets cases linger until a pinky finger from 2008 ends up turning into hand, arm, neck, back, internal, sleep, psyche, etc., etc. - on a case that was really ready to settle no less than 4 years ago.
She asks, "Why would these cases still be open (excluding those with obvious complex if not catastrophic issues) when the file reflects many opportunities for settlement that slipped away?"
Of...
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Thursday, August 29, 2013

Claims Adjuster, TPA Could Face Criminal Charges for Worker Fatality



Today's post was shared by WCBlog and comes from www.propertycasualty360.com


The egregious ­mismanagement
of a California workers’ compensation
claim is being blamed for an
injured worker’s severe infection
and resultant death.

The ongoing case is drawing ire from various associations, including the California Applicants’ Attorneys Association (CAAA), which is lobbying that criminal charges be filed against Sedgwick Claims Management Services, the third-party administrator involved in the claim, as well as one of its adjusters.

The initial workers’ compensation claim originated when Charles Romano injured his shoulder and cervical spine on Dec. 20, 2003 while stocking shelves at a Ralph’s grocery store (part of The Kroger Co.) in Camarillo, Calif. After undergoing surgery for the resultant injuries on August 29, 2005, Romano contracted methicillin-resistant straphylococcus aureus (MRSA), which not only caused renal and pulmonary failure but also paralysis below the shoulders (from C8 down).

Romano later sought treatment for the serious infection at the Ventura County Medical Center, where he had no choice but to use Medi-Cal—the state’s version of Medicaid—because Sedgwick refused to authorize treatment. In fact, Medi-Cal paid for Romano’s medical bills dating from November 2005 through February 2007, ultimately picking up a tab for $300,000.

Fatal Consequences
On October 25, 2006, a workers’ compensation judge issued an amended findings and award,ruling that the MRSA infection was a...
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