NJ Commissioner of Labor Adopts Rules for Emergent Medical Motions in Workers Compensation Matters

David J. Socolow, Commissioner of Labor and Workforce Development, on September 3, 2009, formally adopted the pending Rules for Emergent Medical Motions. The new Rules became effective on Monday, October 5, 2009 and a notice published in the NJ Register on that date, 41 NJ Register 3807(a).

A public hearing concerning the pending Rules was held on June 2, 2009 and there were no attendees. A written comment was submitted by Kenneth A. Stoller, Senior Counsel, American Insurance Association, Washington, DC. One comment concerned the assessment of fines against an insurance carrier for activities of the employer. The Department declined to modify the pending Rules, but stated, “…the insurance carrier would not be fined or penalized where it is in no way culpable for the violation.”

A typographical correction was recognized. “Upon review, the Department has noticed a typographical error, which it would like to correct through a change on adoption. Specifically, the reference within proposed N.J.A.C. 12:235-3.3(r) to, "the decision and order rendered under (o) above," should read, "the decision and order rendered under (q) above..." Consequently, the Department is substituting "(q)" for "(o)" within N.J.A.C. 12:235-3.3(r).”

The Honorable Peter J. Calderone, Director and Chief Judge of the Division, will discuss the new Rules in an upcoming academic seminar sponsored by the NJ Institute for Continuing Legal Education on Wednesday, October 7, 2009.

………

The Rules:

12:235-3.2 General motions for temporary disability and/or medical benefits

(a)-(i) (No change.)

12:235-3.3 Motions for emergent medical care pursuant to N.J.S.A. 34:15-15.3

(a) With or after the filing of a claim petition, a petitioner may file a motion for emergent medical care directly with the district office to which the petition is or will be assigned (See N.J.A.C. 12:235-3.1 for claim petition filing and assignment).

(b) The notice of motion for emergent medical care shall be on a form prescribed by the Division and shall contain or be accompanied by the following:

1. A statement by the petitioner or the petitioner's attorney of the specific request(s) for medical treatment made by the petitioner or the petitioner's attorney to the employer and/or the employer's insurance carrier, including the name of the person(s) to whom the request(s) was/were made;

2. Medical documentation, including a statement by a physician indicating that the petitioner is in need of emergent medical care, that the delay in treatment will result in irreparable harm or damage to the petitioner and the specific nature of the irreparable harm or damage;

3. All medical records relating to the requested medical care, which are in the possession of the petitioner or the petitioner's attorney;

4. Copies of the claim petition and answer.

i. If no answer to the claim petition has been filed, the notice of motion shall include the following information if known by the petitioner: the telephone number and the fax number of the employer, the name of the employer's workers' compensation insurance carrier and the insurance carrier or self-insured employer contact person's telephone number and fax number, as required to be maintained under N.J.A.C. 12:235-3.4; and

5. Proof of service under (c), (d) and (e) below.

(c) Where an answer to the claim petition has been filed by the respondent, the notice of motion and supporting papers shall be served on respondent's attorney by fax and by a one-day delivery service.

(d) Where no answer to the claim petition has been filed by the respondent, the notice of motion and supporting papers shall be served on the employer and, if known by the petitioner, upon the employer's insurance carrier.

1. Service on the employer under this subsection shall be either by personal service or by fax and a one-day delivery service.

2. Service on the insurance carrier under this subsection shall be by fax and a one-day delivery service to the contact person listed pursuant to N.J.A.C. 12:235-3.4.

(e) Where the employer is uninsured or where the employer's insurer is not known by the petitioner, the notice of motion and supporting papers shall, in addition to the requirements under (c) or (d) above, be served on the Uninsured Employer's Fund by fax and by a one-day delivery service.

(f) The date of the personal service, the date of the fax service or the date of receipt of the one-day delivery service, whichever is latest, shall be considered the date of service under (c), (d) and (e) above.

(g) No later than five calendar days after receiving service of the petitioner's notice of motion for emergent medical care, the respondent shall file with the district office an answer to the motion.

(h) Within 15 calendar days after the petitioner has served the notice of motion for emergent medical care upon the appropriate party or parties under (c), (d) and (e) above, the employer or the employer's insurance carrier may have a medical examination of petitioner conducted.

(i) The petitioner is required to attend and cooperate with the medical examination process under (h) above.

(j) Motions for emergent medical care shall take precedence over all other court listings.

(k) The judge should use telephone conferences and afternoon hearings, as appropriate, to expedite the disposition of motions for emergent medical care and to avoid as much as possible the disruption of other court proceedings.

(l) Within five calendar days of the filing of an answer by respondent or, if no answer has been filed, within five calendar days from the date an answer should have been filed, an initial conference on the motion for emergent medical care shall take place.

(m) The district office shall provide notice of the initial conference to the following parties under the following circumstances:

1. Where an answer to the notice of motion for emergent medical care has been filed, the district office shall provide notice of the initial conference by telephone and fax to the petitioner's attorney or petitioner pro se and to the answering party using the telephone numbers and fax numbers indicated in the notice of motion for emergent medical care and the answer, respectively;

2. Where an answer to the notice of motion for emergent medical care has not been filed and where the employer is insured, the district office shall provide notice of the initial conference by telephone and fax to the employer and to the insurance carrier contact person listed in the notice of motion for emergent medical care; or

3. Where an answer to the notice of motion for emergent medical care has not been filed and where the employer is not insured or the insurer is not known, the district office shall provide notice of the initial conference by telephone and fax to the employer and to the Uninsured Employer's Fund.

(n) If the motion for emergent medical care has not been resolved at the initial conference and the employer or the employer's insurance carrier has not requested a medical examination of the petitioner under (h) above, the judge shall hold a hearing on the merits of the motion for emergent medical care as soon as is practicable, but no later than five calendar days from the date of the initial conference.

(o) If the motion for emergent medical care has not been resolved at the initial conference and the employer or employer's insurance carrier has requested a medical examination of the petitioner under (h) above, the judge shall hold a hearing on the merits of the motion for emergent medical care as soon as is practicable after the medical examination of the petitioner, but no later than five calendar days from the date of the medical examination of the petitioner.

(p) With regard to the hearing on the merits of the motion for emergent medical care, the judge may require a continuous trial or may use other procedures to ensure that the motion is expeditiously heard.

(q) The judge hearing the motion for emergent medical care shall render a decision and issue an order on the motion within one business day of the conclusion of the trial testimony.

(r) The judge may supplement the decision and order rendered under(q)above at a later date.

(s) If a motion for emergent medical care does not meet the requirements under this section, but does meet the requirements for a general motion for temporary and/or medical benefits under N.J.A.C. 12:235-3.3, the motion shall be listed and proceed as a general motion for temporary and/or medical benefits.

12:235-3.4 Insurance carrier or self-insured employer contact person procedures pursuant to N.J.S.A. 34:15-15.4

(a) Every insurance carrier providing workers' compensation insurance and every workers' compensation self-insured employer shall designate a contact person who is responsible for responding to issues concerning medical and temporary disability benefits where no claim petition has been filed or where a claim petition has not been answered.

(b) The contact person referred to in (a) above shall also receive notice of motions for emergent medical care under N.J.A.C. 12:235-3.3.

(c) The full name, telephone number, mailing address, e-mail address and fax number of the contact person referred to in (a) above shall be submitted to the Division utilizing the Division's contact person form in the manner instructed on the form.

(d) The Division's contact person form shall be made available on the Division's website and at the Division's district offices.

(e) Any changes of contact person or in information about the contact person shall be immediately submitted to the Division using the Division's contact person form.

(f) After an answer to a claim petition has been filed, the attorney of record for the respondent shall be the point of contact for issues concerning temporary disability and/or medical benefits.

(g) A contact person roster using the information provided under (c) above will be available on the Division's website.

(h) Failure to comply with the requirements of N.J.S.A. 34:15-15.4 or this section shall result in a fine of $2,500 for each day of noncompliance, which fine shall be payable to the Second Injury Fund.

1. The Division shall send notice of noncompliance and of the fine amount by certified mail, return receipt requested, to the business address of the insurance carrier or self-insured employer.

2. The insurance carrier or self-insured employer shall have 30 calendar days to pay the fine or to contest the fine.

3. Where the insurance carrier or self-insured employer contests the fine, the Division shall hold a conference in an attempt to resolve the dispute.

Recodify existing N.J.A.C. 12:235-3.3 through 3.13 as 3.5 through 3.15 (No change in text.)

12:235-3.16 Enforcement

(a) A party may, by written motion pursuant to N.J.A.C. 12:235-3.5(a) and (b), move against an employer, insurance carrier, petitioner, case attorney or any other party to a claim petition for enforcement of any court order or for the enforcement of the requirements of the workers' compensation statute or rules.

(b) The motion under (a) above shall identify the order, statute or regulation sought to be enforced.

(c) The party against whom the motion has been brought shall file a written response to the motion within 14 calendar days of the notice of motion.

(d) The response under (c) above shall include the reasons for any noncompliance and the manner and time period to ensure compliance.

(e) Any time after the 14-day period to respond under (c) above has elapsed and on notice to the parties, the judge shall hold a hearing on the motion.

(f) A judge on his or her own motion may at any time, upon notice to the affected parties, move to enforce a court order or to enforce the requirements of the workers' compensation statute or rules.

(g) Prior to ruling on a motion under (f) above, the judge shall provide the parties an opportunity to respond to the motion and to be heard on the record.

(h) Upon a finding by a judge of noncompliance with a court order or the workers' compensation statute or rules, the judge, in addition to any other remedy provided by law, may take any or all of the following actions:

1. Impose costs and simple interest on any monies due.

i. The judge may impose an additional assessment not to exceed 25 percent on any moneys due if the judge finds the payment delay to be unreasonable;

2. Levy fines or other penalties on parties or case attorneys in an amount not to exceed $5,000 for unreasonable delay or continued noncompliance.

i. A fine shall be imposed by the judge as a form of pecuniary punishment.

ii. A penalty shall be imposed by the judge to reimburse the Division's administrative costs.

iii. The proceeds under this paragraph shall be paid into the Second Injury Fund;

3. Close proofs, dismiss a claim or suppress a defense as to any party;

4. Exclude evidence or witnesses;

5. Take other appropriate case-related action to ensure compliance; and/or

6. Allow a reasonable counsel fee to a prevailing party, where supported by an affidavit of services.

(i) Upon a finding by a judge of noncompliance by a party with a court order or the workers' compensation law or rules, the judge, in addition to any other remedy provided by law, may hold a separate hearing on the issue of contempt.

(j) Following a hearing under (i) above and upon a finding by the judge of contempt, the successful party in the contempt hearing or the judge may file a motion with the Superior Court for contempt action.

(k) Any fine, penalty, assessment or cost imposed by a judge under this section shall be paid by the entity or party found to be in noncompliance and shall not be included in the expense base of an insurance carrier for the purpose of determining rates or as a reimbursement or case expense.

Recodify existing N.J.A.C. 12:235-3.15 and 3.16 as 3.17 and 3.18 (No change in text.)

SUBCHAPTER 7. UNINSURED EMPLOYER'S FUND

12:235-7.1 Purpose; scope

(a)-(d) (No change.)

(e) A petitioner may move to relax or dispense with requirements under this subchapter.

1. After a hearing on the motion to relax or dispense with requirements under this subchapter, the judge may grant the motion upon a finding that the subject requirements under the particular facts of the case are unduly burdensome and that grant of the motion would not adversely affect the UEF.

(f) Where petitioner seeks current medical treatment and/or temporary disability benefits and the only issue is the cancellation or non-renewal of an insurance policy, the judge may order the insurance carrier to provide treatment and/or benefits without prejudice and subject to reimbursement by the employer or, if not paid by the employer, by the UEF, if it is subsequently determined that the policy was not in effect.

(g) (No change in text.)

12:235-7.4 Medical bills; physician's examination

(a) Any medical bills or charges for which petitioner seeks payment from the UEF must be timely submitted by the petitioner to the UEF and be supported by the following:

1. Related treating records, itemized bills and a physician's report, which reflects that the bills and charges were reasonable, necessary and causally related to the work accident or occupational exposure alleged in the claim petition; and

2. Other necessary medical documentation or information required by the UEF.

(b) Any dispute under this section concerning the treating records, bills, physician's report or UEF request for other medical documentation or information shall be determined by the judge after a hearing upon oral or written motion by the UEF or another party.

Recodify existing (b)-(e) as (c)-(f) (No change in text.)

For more information concerning medical care and workers’ compensation click here.

DWC's IMR Meetings Premature

The noise over the volume of Independent Medical Review requests and Maximus' inability to cope with that volume is at top level and the California Workers' Compensation Institute's latest research paper is certainly going to add to the fury. The Division of Workers' Compensation has scheduled round table meetings with interested groups for Monday and Tuesday. CWCI's release couldn't be more timely. CWCI says that basically IMR (and underlying Utilization Review) are working as intended. The say that only 5.9% of requested medical procedures are delayed, denied or modified through utilization review, and that three out of every four medical treatment requests are approved by claims adjusters without the need for additional oversight. Moreover, CWCI found 76.6% of the 919,370 treatment requests it evaluated that were sent out for physician review were approved, 6.6% were modified and 16.9% were denied. One-in-four treatment requests being sent for physician review and one-in-four of those physician-reviewed requests denying or modifying the recommendation means that 94.1% of treatments are approved and 5.9% are denied. CWCI also reviewed 1,141 independent medical-review decisions that had been issued as of Jan. 2 and found 78.9% of denials are upheld by the administrative review and 21.1% are overturned. Of the 919,370 medical treatment requests reviewed by CWCi researchers, "pharmacy" garnered fully 43% of all events - this is an astounding number and debunks quite a...

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Workers’ Compensation 2013 – What Happens on the Other Side of The Fiscal Cliff?

The fiscal reality is that workers’ compensation is in greater jeopardy than ever before as the debate in Washington is not about the deficit at all. The debate is about government spending which includes health care.

Overall health care devours 18 percent of the US economy and amounts to 25% of the Federal budget.

Medical treatment for injured workers continues to be delayed, denied and limited under current workers’ compensation programs. 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 emerge to offer “Opt Out” and “Carve Out Programs,” they are not global enough to solve the critical budget deficit issues. The latest emerging trend is for employers to utilize ERISA based medical care plans to efficiently delivery medical care. In NJ a limited alternate dispute-resolution procedure between unions and employers has been introduced. See “NJ Care Outs –Another Evolutionary Step” authored by David DePaolo.

The US economy continues to be very weak. This in an ominous signal for the nation’s workers’ compensation program which is starved for premium dollars. Premiums are based upon salaries and real median incomes continued their dramatic decline over the last decade from $54,841 in 2000 to $50,054 in 2011. There just may not be enough dollars available in the workers’ compensation programs to pay for present and lifetime medical care.

Even the present Federal system leaves much to be desired. Whether Federal rationing medical care becomes a reality is unknown. Physicians are under economic scrutiny as the “Doc Fix” to limit provider fees continues as a cloud over all medical programs. The agreement reached by Congress still does not resolve the 26.5% percent cut reimbursement cut to physicians who treat Medicare patients. The law merely "freezes" payment to physicians.

Workers’ compensation programs presently structured provide no real economic incentive to monitor and compensate for more favorable medical outcomes. On the other hand, the Federal government, with broad and sweeping regulatory ability, is able to continue to make strides in many areas including present incentives to hospitals and proposed incentives to physicians to provide medical treatment with fewer complications and ultimate better outcomes

Steven Ratner in the NY Times points out the dramatic increase in the nation’s health care costs. He wrote, “…no budget-busting factor looms larger than the soaring cost of government-financed health care, particularly Medicare and Medicaid.”

Solving the economic gridlock of the country will require an approach to re-invent a medical program for injured workers. A global single-payer program under Federal control will eliminate duplicative administrative State and private efforts. The Federal government has the clout to provide efficient enforcement and co-ordination.

Now that we are on the other side of the fiscal cliff, the opportunity to be creative is possible. The US needs to transition to a single-payer health care system subsuming a medical care program for injured and ill workers who suffer both traumatic and occupational conditions.

Read more about the "single-Payer System" and workers' compensation

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NJ Urged to Adopt Single Payer System for Workmens Comp
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Workers' Compensation Medical Benefits are in Critical Condition

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 companies failing, unemployment increasing, the cost of medical care soaring, more attention has now been placed on the elimination of medical care as a workers’ compensation benefit paid by Industry.

It is not all surprising that Dr. Peter Barth reported to the WCRI Conference in Boston, that workers’ compensation programs may be swept up into a national health care system. He reminds us that this was attempted in the Clinton proposal. The enactment of such a proposal looks even more urgent now.

The medical system overall is now being stressed by: an aging workforce; medical conditions manifested by stress and aging; consumerism in health care; the attempt to shift costs from major medical plans and CMS to workers’ compensation; new and expensive treatment modalities, procedures and pharmaceutical products,and the expansion of palliative and “end of life care.” It is anticipated that the average cost may amount to $500.000 per claim.

The workers’ compensation system just can’t deliver medical treatment quickly and cheaply enough. The systems are frough with administrative costs delay. It is adversarial requiring legal timetables of investigation, litigation, adjudication and appeals. The progress of disease is not subject to court rules or judicial administration. Immediate and emergent medical treatment protocols follow a biological timetable not a legal one.

National health reform that embodies workers’ compensation as an element is a long awaited solution to coordinate and advance the delivery of health care to all Americans. Old, inefficient and archaic systems need to be abandoned if progress is to advance. Moving forward to the inclusion of workers' compensation into a universal and nationalized program for health care is an important and innovative change. The change is crticial and necessary to advance with science, the economy and the social structure of America.

Well-documented Expense Records Increase Value of Your M&T Reimbursement

Today's post comes from guest author Michael Furdyna from Pasternack Tilker Ziegler Walsh Stanton & Romano.

While receiving medical treatment related to a workers' compensation case, claimants often have additional expenses such as mileage, fuel costs, transportation fares, and out-of-pocket prescriptions. Yet many claimants don't realize they are entitled to reimbursement for expenses they incur in obtaining treatment. Submitting information related to these expenses is an important part of the workers' compensation process. Problems can arise, however, when incomplete or disorganized information is provided to an insurance carrier. This can result in delays and errors in receiving the proper amount to which they are entitled. Claimants can avoid these sorts of problems with small acts of diligence and record keeping.
Here are a few suggestions:

• Save your receipts and keep a record of your doctor visits. Keeping a log and saving receipts incurred from specific doctor visits provides a “narrative” that makes it easier to tie together dates and expenses.
• Make sure to use the correct form. The New York State WCB requires

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.

.......

For more on "medical treatment" and workers' compensation, click here.

The Great California Trade Off 2012

Rumors spread like wildfire this week as alleged secret back-room dealing continued in an effort to reform the failing California workers compensation system, yet again. The great trade-off of 2012 appears to be a major move to control and limit medical delivery and disability benefits at all cost.

Of critical importance is the fact that as goes California so goes the nation. Historically, changes made in California will slowly advance across the country and become adopted as a national wave of reform.

What has been leaked to the media, and some stakeholders, by a coalition of Labor and Industry management representatives, is yet another bandaid attempt to to control medical delivery in an effort to reduce both treatment costs, and ultimately reduce the number of cases utilizing the system.

While on the books it looks great that injured workers may get a potential increase of $700 million in increased permanent disability benefits, the trade-off is the imposition of a stringently controlled, speeded-up, and rationed medical benefits.

For employers to truly benefit from a Workers' Compensation program that works, employees need to receive the best medical treatment available to cure and relieve their work related medical conditions, and an adequate program of disability payments.

The proposed reforms limit medical choice, limit medical protocols, take away disability modifiers and impose penalties for out of network medical care in the name of expediency.

The problems facing California are not unique to that state. The entire nation, both within the workers' compensation system, and without, are facing similar issues.

One would hope that California would set a high standard for the nation, such as it attempted to do with heightened requirements for automobile emission testing and safety. However, to eliminate treatment options available to injured workers merely for the purpose reducing costs is a fast track program that ignores the need to achieve the best medical result and provide adequate compensation to injured workers.

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California’s Independent Medical Review System Unreasonably Denies Injured Workers Benefits

A California Appellate review panel recently decided that insurance companies and employers had acted in bad faith in applying provisions of the statute concerning Independent Medical Reviews. An injured worker had been denied pain relief medication contrary to the law.

In article published by lexisnexis.com a leading California Workers’ Compensation attorney, past president of the California Applicants Attorneys Association, and author, Melissa C. Brown, Esq.,

discusses Adel Salem v Riverside County WCAB CA.

“Once again, the WCAB gets it,” says Melissa C. Brown, of Fraulob, Brown, Gowen & Snapp, PLC. “Medical treatment denials that ignore the injured worker’s medical condition as a whole are not issued in good faith.” But Brown believes what Adel Salem suffered in this case would not be remedied by the “watered down” penalty provisions of Labor Code Section 5814, and that “the penalty is no deterrent; it is too little, too late.” Brown explains that the UR denial that occurred in Salem happens hundreds of times a week. “They are SOP,” says Brown. “Insurance companies and self-insured employers would rather pay UR companies and Maximus than follow common sense policies which leave routine and ongoing medical treatment decisions to treating doctors, most of whom are in their own MPNs.” In her opinion, Salem showcases the wholesale erosion of basic benefits to injured workers. “Thousands of workers are seeing their long term and effective treatment regimens terminated with no right to judicial review on the merits,” according to Brown.

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The Lack of Equality in the CMS Reimbursement Policy

The current debate on national health care has brought to the forefront some of the most glaring problems that are compounding the workers’ compensation medical delivery system. Since the enactment of The Medicare Secondary Payer Act (MSP) in 1980, the Federal Government has desperately tried to prevent cost shifting from the workers’ compensation system to the Federal Medicare program. The efforts of The Centers for Medicare and Medicaid Service (CMS) to seek medical reimbursement of past and future medical care costs from workers’ compensation beneficiaries, in a uniform fashion across the entire national spectrum, is plagued with equality issues.

In a very insightful article, Robert Pear of The New York Times on June 9, 2009 reported that costs of medical care were not uniform through out the nation and that an increase in expenditures for treatment did not improve the outcome. These “disparities,” as Pear points out demonstrate major fluctuations in the cost of Medicare payments for the same types of treatment. “Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.”

The costs for medical care paid by Medicare based upon geographical jurisdictions are unequal. More specifically, higher costs states were reported to be: Florida, Massachusetts, New Jersey and New York. The lower cost states were reported as: Iowa, Minnesota, Montana, North Dakota, Oregon and Washington.

CMS has sought to seek reimbursement under the MSP Act for medical care, present and future, based on a nationally tailored program. Unfortunately, the benefits paid by each state program are not the same.

While the program to deter the shift of billions of dollars Medicare funds yearly to pay for work related injuries and disease is a noble goal and legitimate function, it is now unequally applied to beneficiaries across the country since all workers’ compensation benefit programs are not the same and the costs of medical treatment vary.

The need for uniformity and equality should be address by Congress as it debates the future of medical care legislation. The enactment of a single payer medical care system would be a good first step to leveling the playing field for both employers and employees.