Medical costs now constitute a huge percentage of every workers' compensation claim. A recent editorial published in New Hampshire asserts that soaring and unequal medical costs have broken the workers' compensation system. Today's post is shared from concordmonitor.com/
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.
Showing posts sorted by relevance for query medical. Sort by date Show all posts
Showing posts sorted by relevance for query medical. Sort by date Show all posts
Sunday, January 11, 2015
Thursday, October 24, 2013
California: Medical Delay and Denial Protested
Sedgwick vs. The People
Round 4: Sedgwick v. Debbye Mazzucca
Operating Room Nurse’s Injury no Emergency to Kaiser, Insurer: Defy Judge’s Order, Refuse to Provide Urgent Medical Care Injured Workers’ Advocates to Seek Penalties, Investigation
.gif "Injured Kaiser OR nurse Debbye Mazzucca tells how Sedgwick defied a judge's order to provide care")
The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today held a news conference outside Kaiser Foundation Hospital with Debbye Mazzucca, a former operating room nurse who was injured while working there. They called for sanctions against Sedgwick Claims Services, Kaiser’s workers’ compensation insurer, for defying a judge’s order to provide Ms. Mazzucca urgently needed medical care, causing her to lose her teeth. On February 11, 2013, the Workers’ Compensation Appeals Board (WCAB) ordered that Sedgwick “shall” provide dental treatment to Ms. Mazzucca. After eight months, Sedgwick and Kaiser have still refused to do so. Sedgwick faces a relatively small monetary penalty for ignoring the court order, which means little to a huge corporation.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.
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
The State of NJ has recently adopted an "electronic medical bill" process. N.J.S.A. 34:15-144, P.L 2016, c. 64. On October 16, 2017, Regulations were proposed to implement the Statute. Public Hearing will be held on Tuesday, November 14, 2017, 10:00 A.M. to 12:00 Noon. The deadline for written comments is December 15, 2017.
Thursday, December 11, 2008
Medical Costs Soar in Workers' Compensation
The cost of medical care has increased tremendously according to a recently issued report. The NCCI (National Council on Compensation Insurance Inc.) reports an increase in medical costs from 40% in the early 1980s to almost 60% currently.
NCCI reports that the increase appears to be national, "....Furthermore, although there are differences in the medical share by state, the change in the relative mix of states has had very little impact on the estimated countrywide share of medical and indemnity benefits."
The national workers' compensation medical delivery system has now become a focus of attention in light of the prospects of an overhaul of national health care system as medical costs continue to put American businesses at a economic disadvantage with foreign competitors. James Kvaal, in his article, "The Economic Imperative for Health Reform," highlights that "...ever rising medical costs are threatening to drive an unsustainable explosion in the national debt." Higher insurance premiums result in lower wages or lack of medical coverage all together and the loss of preventive care.
The costly and inadequate workers' compensation medical delivery system provides a fragmented approach to medical care. The system's focus should treat current medical conditions and provide for preventive care. The administrative costs savings in providing global coverage will translate into reduced delivery costs and a healthier work force. Some of the extra savings could be well spent on much needed medical research to avoid the need for costly medical care.
Wednesday, November 18, 2015
NJ Medical Payments Stabilize - But Why?
A recent study by an insurance based data organization has reported that NJ is experiencing a leveling of medical costs. The real question is "why?" Are declining medical benefits caused by fewer claims based on a shift of challenging employment status in the shared economy or a shift of medical costs under Obamacare to the private sector?
Medical payments per workers’ compensation claim in New Jersey were stable from 2010 to 2013, in contrast to rapid growth in the 2008 to 2010 period, according to a recent study by the Workers Compensation Research Institute (WCRI).
The report, CompScope™ Medical Benchmarks for New Jersey, 16th Edition, indicates results for New Jersey differed from those of other states WCRI studied, many of which experienced moderate to rapid growth in medical payments per claim.
The study found the following to be contributing factors:
- 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.
“From 2010 to 2013, medical payments per claim with more than seven days of lost time rose less than 2 percent per year in New Jersey,” said Ramona Tanabe, executive vice president and counsel for WCRI. “From 2008 to 2010, payments rose nearly 10 percent per year.”
WCRI studied medical payments, prices, and utilization in 17 states, including New Jersey, looking at claim experience through 2014 on injuries that occurred in 2013 or earlier. WCRI’s CompScope™ Medical Benchmark studies compare metrics of medical costs and care from state to state and across time.
Study available for purchase: http://www.wcrinet.org/studies/public/books/csmed16_NJ_book.html.
Sunday, December 19, 2010
Medical Witness Cannot Be An Advocate - Knee Replacement Surgery Authorized
A workers' compensation medical witness is not permitted to be become an advocate. A Judge of Compensation disregarded an insurance company medical witness when the medical expert "crossed the line from being a medical witness to an advocate."
In reaching her decision, Diana Ferriero, Judge of Compensation, rationalized that the insurance company's medical expert by the "convoluted cover letter sent by respondent counsel," along with medical records on the injured worker.
The injured employer suffered two work related accidents as a mechanic for American Airlines. The first accident in to the right knee occurred in July 2004 and resulted in a partial menisectomy and no prolonged sequelae. The worker was symptom free until a second accident in January 2007when he slipped and fell on both knees and hands. The insurance company authorized 28 medical office visits, 15 Hyalgan injections, 14 aspirations and physical therapy for treatment to his right knee. A diagnosis was made by the treating physician and the insurance company refused the injured worker a total knee replacement claiming that the medical condition was unrelated to the 2nd accident of January 2007.
The workers' compensation Judge ordered an independent medical evaluation by a renowned specialist in knee and hip replacements, Mark A, Hartzband of the Hackensack University Medical Center. The judge concluded that, "Dr, Hartzband opined that petitioner's need for a right total knee replacement was directly and causally related to the accident of January 17, 2007."
The court also found that the insurance company's treating physician, who opined that the 2nd accident was unrelated to the need for a knee replacement, was "disingenuous given the contents of his office chart," and reasoned that the insurance company's authorized treating physician did not have an understanding of arthritis and its progression.
The court granted the injured workers' motion for medical treatment, evaluation and scheduling of the right knee replacement, and ordered the payment of temporary medical benefits.
Pepe v. American Airlines, CP No. 2008-5878, NJ DWC 2010), Decided November 11, 2010.
Saturday, January 12, 2013
Medical Outcome Based Compensation - Essentially a Workers' Compensation Concept Already
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| 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)
Nov 09, 2012
On Tuesday, the American people expressed its support for a unified medical care program that will embrace all aspects of life, including industrial accidents and diseases. They validated, as did the Supreme Court, the ...
Jan 10, 2013
Soaring medical costs have afflicted the workers' compensation industry with economic distress and have severely impacted the efficient and effective delivery of medical care to injured workers. Both increased costs/profits ...
Nov 16, 2012
Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the standard of care for the treatment of injured workers with carpal tunnel syndrome;; Modify current MTGs to include new maintenance ...
Jan 01, 2013
Medical costs continue to be shifted to other programs including employer based medical care systems and the Federal safety net of Medicare, Medicaid, Veterans Administration and Tricare. While a trend continues to ...
Thursday, October 8, 2009
New Jersey’s Shining Star
Significant progress has been made by the NJ Division of Workers’ Compensation (NJ-DWC) in carrying out the legislative mandate for the newly enacted emergent medical care motion practice. The Honorable Peter J. Calderone, Director and Chief Judge of the NJ-DWC, delivered a highly favorable report to attorneys attending a workers’ compensation seminar yesterday. The academic seminar was sponsored by the New Jersey Institute for Continuing Legal Education.
Judge Calderone’s report, based on intense statistical tracking and personal involvement of the Director himself, reveals that New Jersey’s injured workers are in fact receiving medical treatment to “cure and relieve their medical conditions” without delay.
The NJ-DWC has approximately 95,000 cases open cases pending in the system each year. The program efficiently and effectively handles disputes as to medical benefits, temporary disability and permanent disability issues.
Two procedural motions are available to parties who seek medical care when a dispute arises. An ordinary motion for medical care, established by regulation, has been utilized for years, if not decades, as an avenue to seek redress. The ordinary motion addresses the needs of the parties who require medical care but their condition is not emergent. These motions are handled at the local hearing office level and their status reported to the Director every 90 days, as they remain pending. Approximately 2% of the pending claims statewide involve such ordinary medical motions.
As a result of concerns expressed in the media approximately 2 years ago, alleging long delays in the handling of claims for emergent medical care, the NJ Legislature, enacted a statutory mechanism to resolve disputes. That motion requires the observance of a stringent time table for judicial action. In those cases, where there is a need for emergent medical care, and the failure to provide it on a timely basis would result in irreparable harm, the new administrative procedures for an emergent medical motion may be invoked.
Immediately following the enactment of the statute, almost a year ago, the NJ-DWC proposed Rules to be followed in processing emergent care motions that would conform with the Legislative mandate. The NJ-DWC operated in conformance with the proposed Rules until they were finally adopted on October 5, 2008, which followed a period for public comment, The rules set forth specific criteria and address procedural compliance issues. The carefully drafted Rules permit those injured workers who are in need of urgent medical care immediate access to the NJ-DWC system for a speedy and efficient resolution of their claim.
Over the last year, Judge Calderone, has taken an active role in reviewing every single motion that has been filed, in consultation with the supervising judge of the district office where the case has been venued. A joint determination was then made as to whether or not the statutory criteria had been met and the procedural and substantive compliance with the rules addressed. If there was compliance by the filing party, the NJ-DWC acted immediately to list the matter for a pre-trial conference in an effort to resolve the dispute before the commencement of a trial. This process remains ongoing.
The statistical evidence reported by Judge Calderone reflects the fact that very few cases have utilized the process, and of those filed, almost all have been resolved within a matter of days on an amicable basis. Within the last year, approximately 50 motions have been filed for emergent medical care, and of those, 16 (32%) had actually satisfied the criteria for filing. Of the 16 that met the criteria to be listed for a conference, all of the cases have been resolved at the conference except for two matters during last year, and those had been set down for trial.
Through the efforts and concerns of the NJ Legislature and the Division of Workers’ Compensation, a good system has been made even better. While this favorable aspect of the NJ workers’ compensation system cannot be globally utilized to solve all the short comings of the national health care crisis, it is a star that shines brightly and may provide some guidance in the on going national health care debate.
.......
Thursday, March 29, 2018
NJ Expands Access to Medical Marijuana to Include Common Work-Related Conditions
Governor Phil Murphy announced major reforms to New Jersey’s Medicinal Marijuana Program. The permitted medical conditions now include many common work-related medical conditions.
Thursday, August 29, 2013
Who Is Paying the Bills for Occupational Illnesses and Disease?
A recently published study from the US Department of Health and Human Services (NIOSH) reports that 45% of emergency room medical expenses for occupational illnesses and disease are not expected to be paid by workers' compensation insurance coverage.
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
Today's post comes from guest author Ryan Benharris (MA) from Deborah G. Kohl Law Offices.
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.
....
Jon L.Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
More About Workers' Compensation and Medical Benefits
More About Workers' Compensation and Medical Benefits
Jul 30, 2011
The just published, Issue 3 of the Workers' Compensation Resources Research Report (WCRRR) provides 23 years of information on cash benefits, medical benefits, and total (cash plus medical) benefits per 100,000 workers ...
Mar 21, 2012
The implementation of the Act will ultimately have far reaching consequences of the overall operation of both the delivery of workers' compensation medical benefits and the ultimate assessment/apportionment of permanent ...
Nov 13, 2008
Now that Barach Obama is a going to be at the helm of the US, greater attention is being focused on the need for a national health care system incorporating workers' compensation medical coverage. With private insurance ...
Aug 29, 2011
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 ...
Monday, August 29, 2011
Pensions, Workers Compensation and Medical Benefits
The State of New Jersey has taken assertive action to guarantee medical benefits to injured workers for their lifetimes even though they are receiving accidental injury pensions. The Director has issued an Administrative Directive requiring language to literally toll the statute of limitations and permit the Division of Workers' Compensation to retain jurisdiction over such matters where the injured worker has accepted the continuing medical benefit option.
"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.
"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.
For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
Wednesday, February 17, 2016
The State of Medical Care in California’s Workers’ Compensation System
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| Katherine Roe |
Todays' guest post is authored by Katie Roe* of the California Bar and was originally published at rivercityattorneys.com/blog (Fraulob & Brown).
When you’re injured at work, you expect that your employer’s insurance carrier will dutifully provide you with proper medical treatment for your injury. After all, future medical care is one of the “benefits” injured workers are entitled to in California. Denial of medical treatment is the number one frustration we hear from our clients on a daily basis.
What injured workers quickly discover is that their medical treatment is strictly controlled by the insurance carrier and their medical fate is in the hands of a doctor who has never treated them and may not even have their complete medical records. This process is called Utilization Review (UR). Under UR an outside physician gets to decide whether or not the insurance company should authorize the medical treatment prescribed by your primary treating physician. This doctor doesn’t even have to be licensed in California.
If the medical treatment prescribed by your physician is denied, your only recourse is to appeal the decision to an Independent Medical Reviewed (IMR). In California, MAXIMUS is the company contracted to conduct IMR reviews. Like UR doctors, the IMR doctor deciding your fate, has never met you or treated you and does not need to be licensed in California. In fact, their identity is protected. If your medical treatment is denied by UR, your chances of IMR overturning the decision are not good. California Workers’ Compensation Institute, an insurance research group, found that 91% of IMR decisions uphold the UR denial. If the treatment is denied by IMR, absent a change in circumstances, the denial will be in effect for one year.
While an injured worker has the right to appeal an IMR determination to the Workers’ Compensation Appeals Board, the only legal bases on which to appeal are fraud, conflict of interest, or mistake of fact. However, even if your appeal is successful the WCAB still cannot overturn the IMR doctor’s decision. If an appeal is granted, the remedy is referral to a different IMR for another review. Yes, you read that right, your award is to go through the IMR process again!
Many injured workers end up seeking treatment for their work related injuries through private insurance, Medicare or Medi-Cal. A study by J. Paul Leigh, a health economist at the University of California, Davis, estimated that only 1/3 of necessary medical treatment and lost wages is being paid for by workers’ compensation insurers.
The lack of adequate medical care for injured workers today is the result of Senate Bill 863, which was passed on August 1, 2012 and signed into law by Governor Brown on September 18, 2012. This law was the result of lobbying by big businesses and insurance companies, who have influence over the State Legislature and the Governor of California. We remind our clients that you also have a political voice. We recommend you go to Voters Injured at Work (www.viaw.org) for information on how to become involved with fixing this broken system.
To read more about the dismal state of medical treatment for injured workers all over America I encourage you to read Insult to Injury by Michael Grabell athttps://www.propublica.org/article/the-demolition-of-workers-compensation.
*Katherine Roe is originally from the San Francisco Bay Area. She attended University of St. Thomas, Saint Paul Minnesota for her undergraduate degree in Sociology with a minor in Criminal Justice. She earned her Master in Public Administration from University of Notre Dame de Namur, Belmont, CA. Katie graduated from University of the Pacific McGeorge School of Law in Sacramento where she received the Witkin Award for Health Law and Elder Law Clinic. She is a practicing attorney in the areas of Workers’ Compensation Law, Social Security Disability and Elder Law, including estate planning with wills, trusts, deeds, powers of attorney and health care directives.
While in college, Katie tutored grade school and high school students in low-income neighborhoods in Saint Paul and Minneapolis, MN and interned with the Oakdale, MN Police Department.
During law school, Katie interned with Legal Aid Society of San Mateo County, Human Rights Fair Housing Commission and the California Department of Insurance. While at McGeorge, she worked in the Elder and Health Law Clinic where she handled Medicare appeals, elder abuse cases, restraining orders, wills, trusts, consumer protection, special needs trusts, and powers of attorney.
While the Clinical Fellow at McGeorge she received the Cohn Sisters’ Scholarship for Patient Advocacy.
While in college, Katie tutored grade school and high school students in low-income neighborhoods in Saint Paul and Minneapolis, MN and interned with the Oakdale, MN Police Department.
During law school, Katie interned with Legal Aid Society of San Mateo County, Human Rights Fair Housing Commission and the California Department of Insurance. While at McGeorge, she worked in the Elder and Health Law Clinic where she handled Medicare appeals, elder abuse cases, restraining orders, wills, trusts, consumer protection, special needs trusts, and powers of attorney.
While the Clinical Fellow at McGeorge she received the Cohn Sisters’ Scholarship for Patient Advocacy.
Friday, November 16, 2012
NY Worker's Compensation Board Proposes New Medical Treatment Guidelines
New York Worker’s Compensation Board’s proposed new medical treatment guidelines that will modify 2010 previously implemented.
Carpal Tunnel Syndrome (CTS)
The new CTS MTG provide evidence based guidelines for the treatment of carpal tunnel syndrome, the most common occupational disease experienced in the workers’ compensation system. Like the other MTGs, the CTS MTG should improve the quality of care, speed access to the most beneficial treatment, and control the use of ineffective treatment.
Maintenance Care
The original four MTGs primarily address treatment for the acute and sub-acute phases of injury, with limited recommendations for the management of chronic conditions and chronic pain. As part of its effort to develop chronic pain guidelines, the MAC re-evaluated those recommendations that relate to maintenance care, recognizing that in certain situations maintenance care (chiropractic and occupational/physical therapy) should be available. The revised MTGs will authorize an ongoing maintenance program that can include up to 10 visits per year for those who have a previously observed and documented objective deterioration in functional status without the identified treatment. To be eligible for maintenance care, injured workers with chronic pain must have reached maximum medical improvement (MMI), have a permanent disability, and meet the requirements of the maintenance care program. No variance is allowed from the 10 visit annual maximum.
The new recommendations address a major concern of both providers and payers: the high number of variance requests. To date, more than three quarters of the variance requests are for maintenance care for those with chronic pain. Injured workers will now have access to important maintenance care while payers and providers will be relieved from the administrative burden of handling individual variance requests for this care. The remainder of the chronic pain guidelines is expected to be completed by early 2013.
Process Changes
The regulations also include several changes to simplify the process, reduce conflict, and speed dispute resolution. These consensus changes are the result of suggestions from stakeholders. The changes will achieve the following:
Complete copies of the proposed regulations, new and revised guidelines, complete description of the process changes, draft versions of the new forms, and other information are available on the Proposed Changes to New York Medical Treatment Guidelines page of the Board’s website. The regulations will be published in the November 21, 2012 State Register.
More about workers’ compensation medical treatment
Our Journey Forward on Occupational Medical Care
Nov 09, 2012
On Tuesday, the American people expressed its support for a unified medical care program that will embrace all aspects of life, including industrial accidents and diseases. They validated, as did the Supreme Court, the ...
http://workers-compensation.blogspot.com/
Workers' Compensation Jeopardy: Romney and Medical Costs
Nov 01, 2012
Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers' compensation medical treatment. Proposed changes to the Federal program will indirectly ...
http://workers-compensation.blogspot.com/
Workers' Compensation: Loss of Health Insurance Access: The ...
Nov 05, 2012
On the flip side, the worker's compensation insurance company is supposed to pay for reasonable medical treatment expenses related to the injury; however, the carrier usually hires an “independent” medical doctor to deny ...
http://workers-compensation.blogspot.com/
RICO Case Against Wal-Mart & CMI Settles for $8 Million
Nov 14, 2012
The claim, on behalf of 7,000 Colorado Wal-Mart workers charges conspiracy with: Claims Management Inc., American Home Assurance Co. and Concentra Health Services Inc., to control medical treatment, who may have .
http://workers-compensation.blogspot.com/
- Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the standard of care for the treatment of injured workers with carpal tunnel syndrome;
- Modify current MTGs to include new maintenance care recommendations; and
- Implement consensus changes to simplify the process, reduce litigation and speed dispute resolution.
Carpal Tunnel Syndrome (CTS)
The new CTS MTG provide evidence based guidelines for the treatment of carpal tunnel syndrome, the most common occupational disease experienced in the workers’ compensation system. Like the other MTGs, the CTS MTG should improve the quality of care, speed access to the most beneficial treatment, and control the use of ineffective treatment.
Maintenance Care
The original four MTGs primarily address treatment for the acute and sub-acute phases of injury, with limited recommendations for the management of chronic conditions and chronic pain. As part of its effort to develop chronic pain guidelines, the MAC re-evaluated those recommendations that relate to maintenance care, recognizing that in certain situations maintenance care (chiropractic and occupational/physical therapy) should be available. The revised MTGs will authorize an ongoing maintenance program that can include up to 10 visits per year for those who have a previously observed and documented objective deterioration in functional status without the identified treatment. To be eligible for maintenance care, injured workers with chronic pain must have reached maximum medical improvement (MMI), have a permanent disability, and meet the requirements of the maintenance care program. No variance is allowed from the 10 visit annual maximum.
The new recommendations address a major concern of both providers and payers: the high number of variance requests. To date, more than three quarters of the variance requests are for maintenance care for those with chronic pain. Injured workers will now have access to important maintenance care while payers and providers will be relieved from the administrative burden of handling individual variance requests for this care. The remainder of the chronic pain guidelines is expected to be completed by early 2013.
Process Changes
The regulations also include several changes to simplify the process, reduce conflict, and speed dispute resolution. These consensus changes are the result of suggestions from stakeholders. The changes will achieve the following:
- enable parties to more easily choose resolution by the Medical Director’s Office, which provides faster and less costly dispute resolution;
- clarify and simplify transmission requirements that were resulting in rejection of thousands of variance requests for technical violations;
- allow carriers to partially grant variance requests, thereby expediting care and reducing litigation;
- eliminate submission of duplicate variance requests;
- reduce the number of procedures requiring C-4 Authorization, and
- authorize submission of variance requests through a web-based portal or other technology in the future, should it become available.
Complete copies of the proposed regulations, new and revised guidelines, complete description of the process changes, draft versions of the new forms, and other information are available on the Proposed Changes to New York Medical Treatment Guidelines page of the Board’s website. The regulations will be published in the November 21, 2012 State Register.
More about workers’ compensation medical treatment
Our Journey Forward on Occupational Medical Care
Nov 09, 2012
On Tuesday, the American people expressed its support for a unified medical care program that will embrace all aspects of life, including industrial accidents and diseases. They validated, as did the Supreme Court, the ...
http://workers-compensation.blogspot.com/
Workers' Compensation Jeopardy: Romney and Medical Costs
Nov 01, 2012
Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers' compensation medical treatment. Proposed changes to the Federal program will indirectly ...
http://workers-compensation.blogspot.com/
Workers' Compensation: Loss of Health Insurance Access: The ...
Nov 05, 2012
On the flip side, the worker's compensation insurance company is supposed to pay for reasonable medical treatment expenses related to the injury; however, the carrier usually hires an “independent” medical doctor to deny ...
http://workers-compensation.blogspot.com/
RICO Case Against Wal-Mart & CMI Settles for $8 Million
Nov 14, 2012
The claim, on behalf of 7,000 Colorado Wal-Mart workers charges conspiracy with: Claims Management Inc., American Home Assurance Co. and Concentra Health Services Inc., to control medical treatment, who may have .
http://workers-compensation.blogspot.com/
Friday, December 2, 2011
Penalties for Insurance Companies Who Fail to Pay Enough for Medical Care
Another approach, enacted by the federal government is to compel insurance carriers to pay a certain percentage of premiums collected for medical care, instead of paying large sums for administration expenses. That could be applied to workers' compensation carriers. Instead of paying 80% of the premium to fight the claim, workers' compensation insurance companies should be compelled to pay 80% to cure the medical condition.
Read more about this concept:
HHS Unveils Medical Loss Ratio Rule (Kaiser Health Breaking News)
"The Department of Health and Human Services today released its final medical loss ratio rule. According to an HHS press release, the rule will ensure that health insurance companies spend at least 80 percent of consumers' health insurance premiums on medical care rather than on income, overhead and marketing expenses. "If your insurance company doesn't spend enough of your premium dollars on medical care or quality improvement this year, they'll have to give you rebates next year," said CMS Acting Administrator Marilyn Tavenner, in the release . "This will bring costs down and give insurance companies the incentive to focus on what matters for patients – high quality health care."
...
For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
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Thursday, November 11, 2010
New Jersey Issues Workers Compensation Guidance on Evaluating Disputed Medical Provider Claims
A NJ Workers' Compensation Task Force report has been published that provides guidance to the parties in evaluating disputed medical provider claims. While declaring that, "certainly there are no overnight solutions," the report provides a manual type of suggestions for negotiation, litigation and resolution.
1. The new WCRI report, Benchmarks for Designing Workers’ Compensation Medical Fee Schedules. Fee schedules vary dramatically from state to state and based upon the type of payer;
2. The fees customarily paid for like services within the same community;
3. The fees paid to the same physician or medical provider by other payers for like treatment;
4. The fees billed and the accepted payments for such bills by a given provider. The Court may wish to consider the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers);
5. A review of the Health Insurance Claim Forms (“HCFA”) submitted by the provider to the claim payer and the Explanations of Benefits (“EOB”) that that claim payer sends to the provider. The EOB provides the amount billed for a given procedure or service performed on a particular date of services. The EOB also provides the amount paid and, where applicable, identifies the reason why a disparity may exist in the amount billed and the amount paid. The use of certified professional coders may be employed to review the bill along with the medical records to be sure that it is consistent with CPT coding standards;
6. The HCFAs or EOBs from other medical providers in the same geographic area or community for the same medical treatment provided;
7. Using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few;
8. The type of facility where the procedure was performed. For example, was the services provided at a Level 1 trauma center versus a community hospital;
9. Consideration of whether there was a contract between a claim payer and the medical provider, such as a PPO network, in which case the contract would be controlling;
10. Consideration ofMedicare/Medicaid reimbursement rates;
11. Testimony from medical office personnel as to what services were billed for, the payments received and how the bill was formulated;
12. Consideration of state sanctioned PIP fee schedules;
13. Consideration of commercial carrier authorized payments.
.....
For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.
1. The new WCRI report, Benchmarks for Designing Workers’ Compensation Medical Fee Schedules. Fee schedules vary dramatically from state to state and based upon the type of payer;
2. The fees customarily paid for like services within the same community;
3. The fees paid to the same physician or medical provider by other payers for like treatment;
4. The fees billed and the accepted payments for such bills by a given provider. The Court may wish to consider the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers);
5. A review of the Health Insurance Claim Forms (“HCFA”) submitted by the provider to the claim payer and the Explanations of Benefits (“EOB”) that that claim payer sends to the provider. The EOB provides the amount billed for a given procedure or service performed on a particular date of services. The EOB also provides the amount paid and, where applicable, identifies the reason why a disparity may exist in the amount billed and the amount paid. The use of certified professional coders may be employed to review the bill along with the medical records to be sure that it is consistent with CPT coding standards;
6. The HCFAs or EOBs from other medical providers in the same geographic area or community for the same medical treatment provided;
7. Using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few;
8. The type of facility where the procedure was performed. For example, was the services provided at a Level 1 trauma center versus a community hospital;
9. Consideration of whether there was a contract between a claim payer and the medical provider, such as a PPO network, in which case the contract would be controlling;
10. Consideration ofMedicare/Medicaid reimbursement rates;
11. Testimony from medical office personnel as to what services were billed for, the payments received and how the bill was formulated;
12. Consideration of state sanctioned PIP fee schedules;
13. Consideration of commercial carrier authorized payments.
.....
For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.
Thursday, August 18, 2011
State Acts to Restrict Medical Care
The State of NJ has proposed sweeping regulations to limit the payment of medical care under automobile insurance policies, and this action is seen as yet another signal that workers' compensation medical delivery may become even further restricted. In an effort to reduce insurance premiums, the NJ Department of Banking and Insurance, has proposed massive changes in the manner and method that doctors may bill for medical treatment and diagnostic procedures and has restructured the process for appealing a denied claim.
The regulations prohibit the use of innovative radiological diagnostic testing. "X-ray digitization or computer aided radiographic mensuration reported under CPT 76499 or any other code are not reimburseable under PIP."
The State claims that medical delivery costs are soaring. It has been reported that for every premium dollar that insurance companies receive, they end up spending $1.23 on medical benefits. The regulations are designed to reduce medical services and produce a profitable insurance product.
Furthermore, the purpose of the regulations are to limit legal costs. The sate reported that in one instance a contested medical resulted in the payment of $375 in medical benefits, but the legal costs awarded for that recovery were $3,380.
The comment period for the new rules runs thorough early September 2011. The impact of the regulations is to reduce medical care and diagnostic procedures that will impact resulting workers' compensation benefits. Ironically providing the best medical benefits available would seemingly comply with the intent of the compensation act and ultimately economically benefit the employer by producing a healthy workforce, The process of cost cutting will only ultimately degrade the medical delivery component of workers' compensation even further.
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