The American Insurance Association (AIA) and collateral Industry groups have banned together in a formal attempt to avoid the Federal mandate to reimburse Medicare for conditional medical payments. This is yet a third assault on the responsibility of employers to avoid payment of medical treatment of injured workers and shift the burden upon the ailing and financially strapped Medicare. Two prior legislative attempts to modify the Medicare Secondary Payer Act (MSP) have failed.
The proposal is embraced in recently introduced HR4796. It is an attempt to modify the Medicare Secondary Payment Act by reducing conditional payment responsibilities of Industry.
In the past, failures in the enforcement of reimbursement practices were highlighted in various investigative reports. Since the reporting of those failures, the Centers for Medicare and Medicaid Services (CMS) have enhanced its efforts to seek reimburse. The US Congress has also imposed compulsory employer/insurance carrier reporting requirements.
Recent studies presented at the National Association of Social Insurance (NASI) disclosed that the majority of conditional payment issues arise in occupational claims which traditionally are denied compensability initially by insurance carriers.
A proposal was made at the NASI meeting to provide more effective and efficient delivery of medical care to injured workers. It was suggested that medical coverage in occupational disease claims become the initial responsibility of US Medicare system who then could seek indemnification from insurance carriers and others who may be ultimately responsible. A pilot plan for this type of health care was embodied in the US Senate passed health care legislation.
Click here to read more about health care and workers' compensation.
Showing posts with label heath care. Show all posts
Showing posts with label heath care. Show all posts
Saturday, March 13, 2010
Monday, December 21, 2009
Good Medicine for an Ailing Compensation System
The stage was set last June 17th, when the US Environmental Protection Agency (EPA) declared Libby, Montana, a Public Health Emergency, because of asbestos present at the site. The geographical location was the site of a W.R. Grace vermiculite mine.
The legislative provision was "buried" deep in the legislation at the last moment, reported Robert Pear of the NY Times. The amendment was made Senator Max Baucus of Montana, who lead the Senate legislative committee crafting the legislation. The convoluted political bartering over the last few days reflects a sentinel change in how injured workers may be receiving medical care in the years ahead. It is anticipated that major changes will be offered over the years ahead to modify and expand the coverage.
Occupational diseases have always been problematic to the State workers' compensation systems. They have been subject to serious and costly proof issues. They were "tag along" claims for a compensation system that initially was enacted in 1911 to cover only traumatic claims. The proposed legislation is a first major step to move occupationally induced illnesses into a universal health medical care system and will provide a pilot project for addressing the long awaited need to furnish medical care without serious and costly delays.
By allowing Medicare to become the primary payor and furnish medical care, those without a collateral safety net of insurance will be able to obtain medical care effectively and expeditiously. While cost shifting from workers' compensation to Medicare has been an historically systemic problem in the compensation arena, this legislation maybe a first major step to legitimatize the process. The legislation may allow for great accountability and expansion of the Medicare Secondary Payment Act (MSP) to end cost shifting that has become epidemic in proportion. It is good medicine for an ailing workers' compensation system.
Click here to read more about workers' compensation and universal health care.
Tuesday, December 15, 2009
California Comp is OK, But Just Don't Get Sick
The study misses the focus and humanization of what workers' compensation is all about. The concept of providing a remedial and expeditious remedy to injured workers seems to have been left outside in the company parking lot.
The California problems are not isolated, they are nationally systemic. The system fails to deliver and fails to encourage a safer worker environment. More of the same old thing, as RAND recommends, ie. more business should be covered, and more premiums should be collected, just isn't going to cut it any longer.
Workers' compensation is fine, as long as a worker doesn't get sick. Dormant and latent conditions for the most part remain untreated by the present system. Preventive medical care is non-existent. Medical monitoring is a major struggle to secure.
Occupational disease cases have perpetually lingered through delay and denial tactics, and now the condition needs critical care that a bandaid will not cure. As the NY Times reports in results of a recent poll, the safety net has failed.
Nationally the system needs to re-worked. Injured workers need to receive medical care through an effective and efficient process and not left out in the streets to suffer. Congress needs to act to provide coverage through an expansion of the proposed national health care agenda.
Click here to read more about medical benefits and workers' compensation.
Monday, October 26, 2009
Denial Rates: An Insurance Company Tactic That Compounds the Health Care Delivery Problem
As Congress considers changes in the nation’s health care program, US health insurance companies continue to be scrutinized. The methodologies of how insurance companies deny claims are being investigated.
A certified nurse assistant, Amelia Mendoza, age 52, of West Covina, California, was attacked twice in the same week by a patient while working at Huntington Hospital in Pasadena earlier this year. Amelia suffered injuries that resulted in her suffering a stroke in April, falling into a vegetative state and contracting pneumonia. The hospital insurance carrier cut off medical care for her, forcing her from the hospital, and leaving her family responsible for medical care for Amelia’s work-related injury that is the hospital’s responsibility.
Her husband, Ralph Mendoza, who met with reporters and supporters outside the hospital, commented, “I am shocked and extremely disappointed that Huntington Hospital would treat Amelia this way. Amelia gave her all to her job for more than six years, and she deserves better….Amelia was injured doing her job, and the hospital has avoided its responsibility for months. I watch my wonderful wife, a mother of four children, slip away in a vegetative state and I wonder whether she would be healthy today if the hospital had met its responsibility. I want the medical care that my wife deserves.”
After an attack by a violent patient, Amelia was examined in the hospital’s Emergency Room and told to return to work. After a second attack just two days later, Amelia went to the Emergency Room and was told to go to Huntington Hospital’s in-house workers’ compensation clinic. The hospital was aware that Amelia’s blood pressure was dangerously high after the attack, and that the patient had infectious diseases. The hospital even called Amelia and her husband to warn of the health dangers Amelia faced. Yet the hospital’s clinic turned Amelia away, saying they were too busy to see her. Amelia suffered a stroke less than three hours later. The attacks had caused bleeding in her brain.
“The workers’ compensation carrier, Sedgwick, has denied liability for Amelia’s medical care, claiming that their investigation did not support a claim of injury and no medical evidence supports the claim either,” said Amelia’s attorney, Chelsea Glauber of the Glauber/Berenson Law Firm. “Medical evidence does in fact exist which states in no uncertain terms that Amelia’s condition was caused by these attacks at work. Amelia is trapped in a horrible hell, between two insurance companies trying to avoid responsibility. So Huntington Hospital let Amelia go home, in a vegetative state, to be taken care of by her husband, who no matter how loving and well intentioned, is not qualified to provide the critical care that Amelia needs and deserves. What does it say about these insurance companies and a hospital that they would treat a hard-working human being in this awful manner?”
A recent report on insurance companies denial rates reveals that, “When it comes to claim denials, insurers may be putting profits ahead of patients’ best interests. Most major insurance companies have reassigned their medical directors—the doctors who approve or deny claims for medical reasons—to report to their business managers, whose main responsibility is to boost profits.”
An inefficient system is not helpful to anyone, including injured workers, insurance companies, and employers. Wasteful administration should be curbed. The U.S. healthcare system wastes between $505 billion and $850 billion every year, recently reported Robert Kelley, vice president of healthcare analytics at Thomson Reuters.
Lawmakers must concentrate the U.S. health debate on how the delivery of medical care can be more efficient and effective. Delays and denials presently occurring in the workers’ compensation system continue to highlight the fact that injured workers need a universal health care system.
A certified nurse assistant, Amelia Mendoza, age 52, of West Covina, California, was attacked twice in the same week by a patient while working at Huntington Hospital in Pasadena earlier this year. Amelia suffered injuries that resulted in her suffering a stroke in April, falling into a vegetative state and contracting pneumonia. The hospital insurance carrier cut off medical care for her, forcing her from the hospital, and leaving her family responsible for medical care for Amelia’s work-related injury that is the hospital’s responsibility.
Her husband, Ralph Mendoza, who met with reporters and supporters outside the hospital, commented, “I am shocked and extremely disappointed that Huntington Hospital would treat Amelia this way. Amelia gave her all to her job for more than six years, and she deserves better….Amelia was injured doing her job, and the hospital has avoided its responsibility for months. I watch my wonderful wife, a mother of four children, slip away in a vegetative state and I wonder whether she would be healthy today if the hospital had met its responsibility. I want the medical care that my wife deserves.”
After an attack by a violent patient, Amelia was examined in the hospital’s Emergency Room and told to return to work. After a second attack just two days later, Amelia went to the Emergency Room and was told to go to Huntington Hospital’s in-house workers’ compensation clinic. The hospital was aware that Amelia’s blood pressure was dangerously high after the attack, and that the patient had infectious diseases. The hospital even called Amelia and her husband to warn of the health dangers Amelia faced. Yet the hospital’s clinic turned Amelia away, saying they were too busy to see her. Amelia suffered a stroke less than three hours later. The attacks had caused bleeding in her brain.
“The workers’ compensation carrier, Sedgwick, has denied liability for Amelia’s medical care, claiming that their investigation did not support a claim of injury and no medical evidence supports the claim either,” said Amelia’s attorney, Chelsea Glauber of the Glauber/Berenson Law Firm. “Medical evidence does in fact exist which states in no uncertain terms that Amelia’s condition was caused by these attacks at work. Amelia is trapped in a horrible hell, between two insurance companies trying to avoid responsibility. So Huntington Hospital let Amelia go home, in a vegetative state, to be taken care of by her husband, who no matter how loving and well intentioned, is not qualified to provide the critical care that Amelia needs and deserves. What does it say about these insurance companies and a hospital that they would treat a hard-working human being in this awful manner?”
A recent report on insurance companies denial rates reveals that, “When it comes to claim denials, insurers may be putting profits ahead of patients’ best interests. Most major insurance companies have reassigned their medical directors—the doctors who approve or deny claims for medical reasons—to report to their business managers, whose main responsibility is to boost profits.”
An inefficient system is not helpful to anyone, including injured workers, insurance companies, and employers. Wasteful administration should be curbed. The U.S. healthcare system wastes between $505 billion and $850 billion every year, recently reported Robert Kelley, vice president of healthcare analytics at Thomson Reuters.
Lawmakers must concentrate the U.S. health debate on how the delivery of medical care can be more efficient and effective. Delays and denials presently occurring in the workers’ compensation system continue to highlight the fact that injured workers need a universal health care system.
Thursday, July 2, 2009
C-Span TV: David Michaels Author of "Doubt is Their Product"
David Michaels, former Assistant Secretary of Energy for Environment, Safety, and Health during the Clinton administration contends that corporations hire their own scientists to skew the safety records of certain products. He recently spoke at an event was hosted by the Center for American Progress in Washington, DC. The speech was broadcast by C-Span TV.
David Michaels directs the Project on Scientific Knowledge and Public Policy at the George Washington University School of Public Health and Health Services. Mr. Michaels was formerly Assistant Secretary of Energy for Environment, Safety and Health during the Clinton administration. He received the American Association for the Advancement of Science's Scientific Freedom and Responsibility Award in 2006. Michael authored Doubt is Their Product: How Industry's Assault on Science Threatens Your Health.
Wednesday, November 19, 2008
National Health Leaps Ahead on Agenda
It should no surprise to anyone that the Obama Transition is already targeting national health care as a first year agenda item. With Senator Edward Kennedy and the Clintons anticipated to be major participants in the new Obama Administration, the health care issue has now leaped to forefront.
Senator Kennedy's return to the Senate this week coincided with his announcement of the formation of 3 working groups to assist in the development of heath care legislation. He announced the following participants to his team: Sen. Hillary Rodham Clinton (D-N.Y.); Sen.Barbara Mikulski (D-Md.) and Tom Harkin (D-Iowa). They planned a meeting for today in an effort to plan out the immediate effort. This signals that health care reform will emanate from the Congress and not The White House.
Insurance company reaction was immediate. The carriers offered full medical coverage for pre-existing coverage providing that there was a global requirement for all to be insured.
As this program rolls out it is most certainly anticipated that workers' compensation medical coverage be included in the global effort. Studies have long shown that the litigation progress delays the delivery of benefits, increases administrative costs and depletes much needed medical resources from health research efforts.
Senator Kennedy's return to the Senate this week coincided with his announcement of the formation of 3 working groups to assist in the development of heath care legislation. He announced the following participants to his team: Sen. Hillary Rodham Clinton (D-N.Y.); Sen.Barbara Mikulski (D-Md.) and Tom Harkin (D-Iowa). They planned a meeting for today in an effort to plan out the immediate effort. This signals that health care reform will emanate from the Congress and not The White House.
Insurance company reaction was immediate. The carriers offered full medical coverage for pre-existing coverage providing that there was a global requirement for all to be insured.
As this program rolls out it is most certainly anticipated that workers' compensation medical coverage be included in the global effort. Studies have long shown that the litigation progress delays the delivery of benefits, increases administrative costs and depletes much needed medical resources from health research efforts.
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