Copyright
Monday, November 24, 2014
When An Employer Should Not Deny Medical Care
Sunday, January 8, 2012
PROTECT America's Injured Worker Medical Rights
Why This Is Important
Injured workers are forced to obtain treatment from an inadequate, unspecialized list of providers, often with disastrous long term results and are barred from both timely and appropriate medical treatment through a complex paper trail of denials for basic medical care.
Before long, we’ll have to pay our employers when we’re injured, rather than the other way around.
Deliberate indifference is defined as requiring (1) an "awareness of facts from which the inference could be drawn that a substantial risk of serious harm exists" and (2) the actual "drawing of the inference." Elliott v. Jones, 2009 U.S. Dist. LEXIS 91125 (N.D. Fla. Sept. 1, 2009). (Wikipedia, 2011)
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- Gingrich Calls Present Workers' Compensation System Dangerous (workers-compensation.blogspot.com)
- Contagion in The Workplace: Ready or Not (workers-compensation.blogspot.com)
- The Top 10 Workers' Compensation Blog Posts for 2011 (workers-compensation.blogspot.com)
- Penalties for Insurance Companies Who Fail to Pay Enough for Medical Care (workers-compensation.blogspot.com)
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Wednesday, April 10, 2019
An Employer Must Provide Accommodation for Off-Hours Use of Medical Marijuana
Monday, December 3, 2018
Fee Schedules: A defense of bureaucracy in workers compensation
Friday, February 1, 2013
Universal Medical and Workers' Compensation: It's Not "If", It's "When" - California
My friend, and cycling inspiration, who keeps me trying to think I can enter the Tour de France while under the influence of Starbucks coffee, David DePaolo, points out that the "fusion" may be coming slowly through legislation of unintended consequences in California.
"The concept of universal care, 24 hour care, single stop shop, etc. has been floating for a couple of decades now with very little progress.David, an expert in analyzing what's around the curve, sees the next wave of change coming to workers' compensation. For so many reasons, including the expansion/reimbursement integration of the Medicare program, the writing is on the wall on this one.
"But the passage of the Affordable Care Act, the signing of HB 1 back in February 2009, and other Federal health related laws and regulations including ERISA, have accelerated the fusion of workers' compensation medicine and general health medicine. Outsourcing MPN [Medical Provider Networks] oversight to a health care related agency is just another step towards this outcome.
Every time the lobbyists think that have eliminated the imminent threat of Federal intrusion, ie. Enactment of The SMART Act, the reality of which is that the regulations will eat up the statute, and also their lunch. I plan to write more on The SMART Act in the coming weeks. Maybe that wasn't so smart after all for the cottage industries that supported it.
Sunday, January 11, 2015
High Compensation Medical Costs Raises Concern in New Hampshire
Lawmakers should make 2014 the last year that doctors and other health care providers are guaranteed payment no matter how much they charge when a worker is injured on the job. The workers’ compensation system is broken.
The state, and the employers who pay into its workers’ compensation fund, have been paying two and three times the going rate for medical services when the patient is a workers’ compensation recipient. On average, surgeons charge 156 percent more, according to a report by the state’s Department of Insurance. Bills for radiology are 107 percent higher, 95 percent higher for occupational therapy and for something as simple as an ice pack, 300 percent more.
The extra paperwork required to document workers’ compensation cases and perhaps the added severity of the average injury, probably explains some of the price difference. But, human nature being what it is, it’s likely that, when the bill has to be paid no matter what the provider charges, the temptation to pad it can be irresistible, especially when providers can rationalize the surcharge by using it to offset underpayments in areas such as Medicare or Medicaid.
Thursday, October 24, 2013
California: Medical Delay and Denial Protested
Operating Room Nurse Debbye Mazzucca, of La Mesa, has thirty-five years’ experience, and worked for Kaiser for 12 years. She was injured in 1998, when she tripped and fell over a parking lot barrier while at work. Kaiser treated her injured knee, but ignored multiple doctors’ reports that she had also injured her neck and back. In spite of four doctors reports confirming that fact, Kaiser denied that those injuries were from the fall. Now, due to complications from medications, and delays in approving medical care, Ms. Mazzucca has lost her teeth.
CAAA President Jim Butler said, “Insurers’ Utilization Review (UR) routinely delays and denies doctors’ legitimate requests for appropriate medical treatment. This is unnecessary and expensive, and has got to change. We’ve seen the evidence of out-of-control delay and denial in the 15,000 denials of recommended medical care in just the month of August. It’s time to bring UR to heel, and stop insurance carriers from using it as a routine roadblock.”
“A doctor, agreed to by the company and their insurer, determined this Kaiser operating room nurse’s injury was a result of her work accidents. The insurer still refused to provide urgent medical care. A judge ordered the insurer to provide urgently needed medical care. But Sedgwick continues to refuse medical care and Debbye lost all her teeth during the months of delay,” said Alicia Hawthorne, the president of CAAA’s San Diego chapter, and Ms. Mazzucca’s attorney. “This nurse has been in pain, and in need of medical treatment. Yet, the insurance company defied a judge’s order to provide care. Kaiser and its insurer have spent years fighting their responsibility to treat these injuries. Why does the State of California allow workers’ compensation insurance companies to further damage patients through delaying and denying medical care and disability compensation?”
“Kaiser has failed to provide the care needed to heal my injuries,” Mazzucca told a news conference outside Kaiser Foundation Hospital in San Diego. “For years, all they would approve were painkilling drugs. These drugs’ side effects have caused more medical problems, including ‘dry mouth syndrome,’ which is insidious and dangerous. The drugs prevent your saliva glands from working properly, causing your teeth and gums to deteriorate. Mine became infected, abscessed and threatened my health and my life. In 2010, my teeth started cracking and breaking off at the roots. I lost seven of my teeth this way.”
Sedgwick denied the dental treatment I needed, so Ms. Mazzucca took them to court. In February 2013, the judge ordered Sedgwick to provide this urgent medical treatment. To this day, they have refused to do so. “It has been more than a year and a half since the medical expert the insurer agreed upon said I urgently needed dental care. The pain and infection became so unbearable in July that my doctor sent me to the emergency room, and 25 of my teeth were removed. I then spent the entire month of July in the hospital, in agony, and on painkillers. Kaiser and their insurance company are defying a judge’s order to provide urgently needed medical care,” said Mazzucca.
Today’s release is the fourth in CAAA’s series of cases spotlighting the abuse of Utilization Review (UR) and other methods for delaying and denying legitimate medical care and disability compensation in the workers’ compensation claims handling practices of insurers like Sedgwick Claims Management Services.
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- Florida rejects workers' compensation rate hike (workers-compensation.blogspot.com)
- Where is the Deep Water? (workers-compensation.blogspot.com)
- Study: Calif. workers compensation overhaul too new to parse (workers-compensation.blogspot.com)
- The Government Shutdown is a Kick-In-Gut to Workers' Compensation (workers-compensation.blogspot.com)
- Is Workers' Compensation Just a Promise That Can't Be Kept? (workers-compensation.blogspot.com)
- New York Second in Nation for Questionable Workers' Compensation Claims (workers-compensation.blogspot.com)
Monday, January 5, 2015
NJ Medical Costs Per Claim Increase
NJ is a jurisdiction where the employer has exclusive control over the selection of medical providers for workers' compensation claims. NJ also has no medical fee schedule. Neverthe less, WCRI report that medical costs per claim are increasing above the national average.
The report, CompScope™ Medical Benchmarks for New Jersey, 15th Edition, found medical payments per claim grew less than 3 percent per year from 2010 to 2012―about half the annual rate of the prior three years.
The study cited changes in both key components of medical payments per workers’ compensation claim: the price paid for each service rendered and the number of services performed in each claim (generally called utilization).
The study found a decrease or little change in utilization of many nonhospital services─a key factor in the recent slower growth in medical costs because payments for nonhospital care accounted for roughly two-thirds of medical payments in New Jersey. Slower growth in hospital outpatient payments per service was also a factor. Payments for hospital inpatient treatment continued to rise though.
The recent trends coincided with an increase in the use of networks in caring for injured workers. States that do not regulate reimbursements for medical care through a traditional fee schedule (like New Jersey) often use medical networks to help control medical costs through the management of claims and negotiated payment discounts.
Despite the recent slower growth, medical payments per claim in New Jersey remained higher than most of the 16 states WCRI studied, primarily due to higher prices paid for medical care.
In several states, WCRI researchers saw slowdowns in claims growth similar to what they found in New Jersey, namely growth of 3 percent or less from 2010 to 2012, after growth of 4 to 8 percent a year, on average, from 2007 to 2010. Reasons for the slowdown differed by state, the study said.
The Cambridge-based WCRI is recognized as a leader in providing high-quality, objective information about public policy issues involving workers' compensation systems.
Click on the following link to purchase a copy of this study:http://www.wcrinet.org/result/csmed15_NJ_result.html
Monday, October 23, 2017
Electronic Medical Bills for Workers' Compensation Claims
Thursday, December 11, 2008
Medical Costs Soar in Workers' Compensation
Wednesday, November 18, 2015
NJ Medical Payments Stabilize - But Why?
- Increased use of networks, which may be linked to a decrease in prices paid for non hospital care. In recent years, two-thirds of total medical payments came from non hospital services.
- Flat or decreasing trends in utilization of many non hospital services.
- Slower growth in hospital outpatient payments per service.
- A continued decrease in the percentage of claims that had hospital inpatient care.
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- NJ State Bar Association Opposes Workers' Compensation COLA Bill (workers-compensation.blogspot.com)
- NJ Medical Costs Per Claim Increase (workers-compensation.blogspot.com)
- High Compensation Medical Costs Raises Concern in New Hampshire (workers-compensation.blogspot.com)
Sunday, December 19, 2010
Medical Witness Cannot Be An Advocate - Knee Replacement Surgery Authorized
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Saturday, January 12, 2013
Medical Outcome Based Compensation - Essentially a Workers' Compensation Concept Already
Outcome Based Medicine Being Adopted by NYC |
In actuality the workets' compensation system rewards the employer for the most favorable outcomes by theoretically awarding lower permanent disabillity benenfits to those with the most favorable outcomes.
Adopting this concept to the nation's entire medical care system, is a wise step and one that is being advanced in the New York City Hospital system.
"In a bold experiment in performance pay, complaints from patients at New York City’s public hospitals and other measures of their care — like how long before they are discharged and how they fare afterward — will be reflected in doctors’ paychecks under a plan being negotiated by the physicians and their hospitals."
Click here to read New York Ties Doctors’ Pay to Quality of Care (NY Times)
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Thursday, October 8, 2009
New Jersey’s Shining Star
Thursday, March 29, 2018
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Thursday, August 29, 2013
Who Is Paying the Bills for Occupational Illnesses and Disease?
Click here to read the complete report: Use of Workers’ Compensation Data for Occupational Safety and Health: Proceedings from June 2012 Workshop (May 2013) Identifying Workers’ Compensation as the Expected Payer in Emergency Department Medical Records, Larry L. Jackson, PhD, Susan J. Derk, MA, Suzanne M. Marsh, MPA, Audrey A. Reichard, OTR, MPH National Institute for Occupational Safety and Health
Thursday, November 8, 2012
Workers’ Compensation Is About Relationships
Prevention of accidents should be the first step in establishing a successful workers’ compensation system. If an employer were truly concerned about the health and safety of the employee there would be no need for workers’ compensation.
Unfortunately the profit motive of the employer sometimes corrupts the process, and shortcuts are taken at work to increase production at an anticipated lower cost to the employer.
Employers need to understand that the human and financial costs of industrial accidents and exposures can be devastating. Injured workers, through the workers’ compensation process, may seek the payment of medical benefits, lost time payments and permanent disability awards.
Hopefully, the relationship between employees and employers can improve, and the workplace can become a safer environment.
....
More About Workers' Compensation and Medical Benefits
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Monday, August 29, 2011
Pensions, Workers Compensation and Medical Benefits
"Petitioner has been awarded and accepted an accidental disability pension effective _(date)_. To resolve the workers' compensation case, petitioner and respondent have agreed to provide petitioner with reasonable and necessary medical treatment for injuries related to the _(date)_ accident. This Order for continuing medical benefits shall not be subject to the two year statute of limitations and such medical benefits shall continue for the life of the petitioner or until further order of this court."
By statute, workers' compensation awards are offset by pension awards. The medical issue remains open usually and medical benefits remain the responsibility of the employer. The medical issue becomes a complication when costs are attempted to be shifted to collateral medical carriers or Medicare. The subsequent reimbursement issue then generates medical lien claims that must be litigated. The incorporation of the language will greatly clarify responsibility and expedite medical care and payment.
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- The Setoff Nightmare: The Pension Well Runs Dry (workers-compensation.blogspot.com)
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- That Used to Be Comp (workers-compensation.blogspot.com)
- N.J. suffers a setback in its credit rating (nj.com)
- State Acts to Restrict Medical Care (workers-compensation.blogspot.com)