Private Claim for Medicare Reimbursement Dismissed

A private suit, brought by a consortium of plaintiff entities and individuals seeking reimbursement of Medicare for the failure of the tobacco companies’ to repay The Centers for Medicare and Medicaid [CMS] for benefits, was dismissed by a Federal. The parties had sought to recovery benefits and damages against Philip Morris USA Inc.

The Court reasoned that the law suit did not demonstrate the tobacco companies’s responsibility for the payment of a Medicare beneficiary’s medical costs. The plaintiff’s had attempted to rely upon the opinion in a bench trial instituted by the Federal government under the RICO Act.

The Federal Court judge held that the defendants, the tobacco companies, “are not subject to suit under the MSP unless and until they are found responsible for Medicare costs and they fail to reimburse Medicare within 120 days after that responsibility first arises.” The suit by the private parties was dismissed.

National Committee to Preserve Social Sec. and Medicare v. Philip Morris USA Inc., ___ F.Supp.2d ___, 2009 WL 590573 E.D.N.Y., March 05, 2009.

Medicare Reporting - $1,000 fine/claim/day

The failure to report claims to Medicare could cost insurance carriers $1,000. per day per claim. The penalties are discussed in a very informative article authored by Stephanie Stacy and Jill Schroeder that appears in The Nebraska Lawyer, March, 2009. A copy has been posted to the Yahoo Workers' Compensation Blog.

The article:
http://tinyurl.com/bthcfm

AMA Guides Tossed Aside in California

The California Workers Compensation Appeals Board has ruled that the 2005 version of the AMA Guides to Impairment need not be followed. The Court ruled:

(1) the AMA Guides portion of the 2005 Schedule is rebuttable;
(2) the AMA Guides portion of the 2005 Schedule is rebutted by showing that an impairment rating based on the AMA Guides would result in a permanent disability award that would be inequitable, disproportionate, and not a fair and accurate measure of the employee’s permanent disability; and
(3) when an impairment rating based on the AMA Guides has been rebutted, the WCAB may make an impairment determination that considers medical opinions that are not based or are only partially based on the AMA Guides.

Almarz v Environmental Recovery, et al
Case No. ADJ1078163 (BAK 0145426) Decided Feb. 3, 2009

AIG Up For Sale

AIG, the distressed insurance company, is expected to announce a $60 Billion quarterly loss. The announcement, anticipated shortly, follows three separate failed efforts by the Federal Government to rescue the company.

Creditors of the company, and the US Government, have reached a four new deal to bailout the company. This time the company is being structured to be sold. It has been reported that the property and casualty lines maybe the first to go. 

The US Treasury and AIG issued the following statement:

"The steps announced today provide tangible evidence of the U.S. government’s commitment to the orderly restructuring of AIG over time in the face of continuing market dislocations and economic deterioration. Orderly restructuring is essential to AIG’s repayment of the support it has received from U.S. taxpayers and to preserving financial stability. The U.S. government is committed to continuing to work with AIG to maintain its ability to meet its obligations as they come due."

Is The Recovery Of The Workers’ Compensation System An Illusion?

The present economic downturn has been compared to the Great Depression of the 1930’s or the recession of the 1980’s. The factors that existed during those financial cycles need to be compared to the present political and economic dynamic to determine whether or not history is repeating itself. Analysis of those two periods provides an insight as to whether or not there will be a rebound or surge of claims in the future.

The depression of the 1930’s occurred at a time when the workers’ compensation program in the United States was in its infancy. The benefits delivered were very limited. Occupational diseases were not included in most acts, the population had a lower life expectancy, early retirement plans did not exist, social security was not yet enacted, and Medicare was only an idea. The federal government poured dollars into the economy to construct public works [WPA] projects while limiting private debt. A consumer based economy didn’t exist at the time of the Great Depression.

Likewise, the recession of the 1980’s had its own characteristics. During the 1980’s, the populations mostly affected by layoffs were those who were the labor force of post-World War II. The workers of that generation suffered from occupational exposures to many deleterious and carcinogenic substances. The occupational diseases were latent in manifestation and epidemic in proportion. Laid-off workers who became victims of the recession of the 1980’s participated in a surge of litigation, both workers’ compensation claims and third-party actions against the manufacturers of toxic substances. Litigation snowballed against , including asbestos manufacturers, suppliers and distributors because of the minimal money recovered in the ordinary workers’ compensation claim. Asbestos litigation became “the longest mass tort in history.” In the years following the 1980’s the many workers separated from their jobs did not return to employment. Instead they collected both workers’ compensation benefits and Social Security disability.

The medical costs incurred, due to their occupational illnesses, were intentionally shifted from the workers’ compensation program to the Social Security Medicare program. The Medicare Secondary Payer Act was enacted by Congress in 1980 to end the cost shifting tactics by employers and their workers’ compensation insurance companies programs, Medicare and health group coverage, and pension offsets.

The current workforce, now being laid-off, is composed of an entirely different demographic than what existed in the 1930s and the 1980s. The social and political factors at the present time are far different from what was facing the workforce of the prior recession/depression years. The US Bureau of Labor Statistics reported, “In January 2009, the unemployment rate of persons with a disability was 13.2 percent, compared with 8.3 percent for persons with no disability, not seasonally adjusted. The employment-population ratio for persons with a disability was 20.0 percent, compared with 65.0 percent for persons with no disability.” The elderly have now been designated as a “new class of workers” as they return to the labor market out of economic desperation. The numbers of unemployed workers who are 65 years old and older now in the workforce, compared to a decade ago, have increased to 7.3% from 4.7%.

The census of workers currently without employment opportunities include significant numbers of aging baby boomers who were about to seek retirement while looking forward to the "golden years." The erosion of planned retirement savings requires that many older workers now return to work. There is a reluctance to file claims. Therefore, fewer injured workers now seek total disability payments under workers’ compensation. The stagnation of the administration of the workers’ compensation system makes it even more difficult for the elderly who are injured to navigate the system. This only adds to the claimant’s frustration and encourages a greater reluctance to file a formal claim for benefits.

Some workers’ compensation insurance companies now involved in the compensation system have been nationalized by the federal government to the various stimulus and bailout programs. They lack funds to remain economically viable with out further insurgence of capital from the federal government. The federal government is now a stakeholder in the process. Self-insured employers are becoming financially weaker. Corporate assets have been minimized by lack of credit and the massive economic stock value decline. Municipal entities and others involved in joint insurance funds (JIFs) are now having difficulty in maintaining economic viability. Because of the lack of tax revenues and federal support, State and local communities are on the verge of bankruptcy.

The present ills of the American workers’ compensation system mirror the economic woes of the national economy. The last decade has demonstrated an accelerated decline in the functioning of the system. It is reflective of what Paul Krugman, Professor of Economics and International Affairs at Princeton University, commented in the NY Times, that Americans are having financial “illusions.” “The bottom line is that there has been basically no wealth creation at all since the turn of the millennium: the net worth of the average American household, adjusted for inflation, is lower now than it was in 2001.” The workers’ compensation system is so bogged down in increasing medical debt that it is unable to deliver benefits efficiently. The present compensation system can’t be relied upon to rebound.

Compounding this downturn in the financial sector is the fact that workplaces have become safer. Over the years there has been a decline in fatalities as reported Bureau of Labor Statistics National Census of Fatal Occupational Injuries. As the United States becomes more of a service-based economy with a dwindling manufacturing sector, less injury risk exists in the occupational sector. The workplace has become safer and there are fewer serious injuries and less occupational illness.

The corporate downturn has been reflected by the implosion of many defense law firms who have reduced their staffs. Over a thousand lawyers were laid-off in a single day by major defense firms. The legal market restructuring is the result of a domino effect of the downsizing of corporate America. Representing injured workers and defending compensation claims on behalf of corporate America has taken a dramatic downturn. The trend is toward less attorney participation in the present system. Even attorney layoffs have become epidemic as the economic downturn intensifies.

Additionally, workers’ compensation programs have been subject to insurance industry targeted reform. The yet number of claims, eligible for benefits that would require legal representation has declined substantially as the California wave of reform swept towards the east coast. As the economies of the States shrink, so do the dollars available to operate the administrative programs for injured workers. Workers’ Compensation hearing offices in California will be closed two days per month and in New Jersey, a state that has already imposed a hiring freeze, is about to similarly close State offices.

The workers’ compensation system, based upon new national social and economic characteristics is already being re-crafted into a new program requiring less need for litigation support. Unlike the Great Depression of the 1930’s and the recession of the 1980’s, the present downturn in workers’ compensation claims activity is not anti-cyclical. It is an illusion of grandeur to believe that the present workers’ compensation system will recover or rebound in its present format. A national universal medical program will ultimately embrace the compensation delivery system and determine the future destiny of workers compensation.

The Right to Choose Your Doctor

Selecting your own treating physician in a workers’ compensation claim may soon become permitted nationally. A movement in Iowa has now sparked national interest to permit employees the right to choose their medical provider.

Coupled with the effort for employees to seek freedom of choice “to form unions and bargain for a better life” is the effort to seek freedom to choice a medical provider in a work-related accident or occupational illness.

The effort has been supported by an interest group formed on Facebook, “Iowians for Workers Choice of Doctor.” “Because life is about more than just work...In Iowa, if you are injured on the job, employers can decide which doctor treats you. You choose what foods you eat and which exercises you do, but they can choose who is best to care for you.”

Iowa Senate Bill 1119 would allow injured workers to designate their choice of physician. “Too much has been made of how much this is going to cost a company and not enough on how this affects an individual and their personal lives,” said Democratic Sen. Bill Dotzler of Waterloo.

The vast majority of states allow workers the freedom to choose their own treating physicians. Studies have shown that employees who have the right to select their own physician have more confidence in their medical care and have a more successful recovery.

The delivery of medical services continues to be a major problem in the national network of workers’ compensation systems now in place since 1911. Federal initiatives for a national healthcare system are under consideration that would incorporate the entire workers’ compensation system’s medical delivery system.

CMS to Provide Query Access Through Mandatory Reporting

At a recently moderated telephone conference session CMS announced that beneficiary verification would be available through a query function on its new database system to determine eligibility Medicare beneficiary status. The system will be in response to new insurance carrier mandatory reporting procedures that have been Congressionally imposed. The query will be based on 4 basic criteria including: Social Security number; data birth; name or gender. The verified Social Security information will be provided for all criteria except Social Security numbers and a corrected format.

CMS will not provide outstanding conditional payments or other data by use of the reporting system. Individual beneficiaries may be able to find this information upon governmental website that allows for individual beneficiary access through http://www.mymedicare.gov/. That site is accessible only by beneficiaries.

The federal is agency is planning for the release of a User Guide prior to the actual date of mandatory deployment and activation of the federal reporting site. Activation is anticipated in July 2009.