Tag Archives: insurance

“Cost-Shifting” Exposed: How Injured Worker Medical Care Decisions Are Made (And Who Pays)

Medical coverage is a topic on everyone’s mind. Obamacare, while controversial, has started a real dialogue in this country regarding health care. Regardless of whether you are in favor of the current law, most Americans want affordable health care for themselves and their families.

Many employers pay for a substantial amount of their workers’ premiums as a benefit to them, and take this into consideration when making salary decisions due to the high cost, thereby leaving workers to pay for all or some of their medical coverage. Sometimes insurers pay for benefits that are not their responsibility because the proper entity refuses to pay. This is known as cost shifting. As a practitioner in the field of Workers’ Compensation, this idea of cost shifting has become an all too common occurrence. 

By way of background, as a result of social reform, most states enacted some form of Workers’ Compensation legislation in the early 20th Century. In exchange for timely payment of medical and indemnity benefits, workers gave up the right to sue their employers. In 2007 in New York, there was a series of further reforms that led to compromise between labor groups, the insurance industry and the Business Counsel. There was an increase in the amount of weekly benefits to injured workers to conform with the State average weekly wage (now a maximum of approximately $800 per week) in exchange for a limit on the amount of weeks an injured worker is entitled to receive these benefits.  Additionally, medical treatment guidelines have been introduced with the premise that they would streamline costs and get injured workers faster and more effective medical care. These guidelines are based upon the principles of Evidence Based Medicine (EBM), which is the use of clinical trials and data to determine whether a specific treatment should be recommended for a specific diagnosis.  It is sometimes referred to as “cookbook” treatment. 

In New York, the Court of Appeals recently ruled by a 4-3 margin that any treatment not specifically included and pre-authorized is presumptively unnecessary. In other words, if a treatment requested is not within the medical treatment guidelines, it is denied. This takes the decision making out of the hands of the treating physician who is really in the best position to determine what treatment would be most beneficial for patients. In order to overcome this presumption, the doctor now must engage in what has been seen in most cases as an exercise in futility to request a variance to overcome this presumption.

The New York Committee for Occupational Safety and Health (NYCOSH) reported that the New York State Workers’ Compensation Board received 202,643 variance requests in the first 10 months the guidelines were implemented. A quarter of the requests were rejected by the Board immediately. The rest can lead to protracted litigation. As a result, in many instances injured workers will now shift the cost to another party, such as their own private insurance, Medicare or even worse, pay for the treatment out of pocket. It is the path of least resistance. We all pay an additional price for medical costs borne by group health insurance carriers, Medicaid, and Medicare that should in fact be paid by Worker’s Compensation insurers. This cost shifting may increase Workers’ Compensation insurance profits, but it hurts both the employers’ and the employees’ bottom line. Injured workers don’t stop needing treatment just because their medical claim is denied. Someone has to pay for the cost of lost time and medical treatment. It is time that the proper party step up and take responsibility.

 

 

Catherine M. Stanton is a senior partner in the law firm of Pasternack Tilker Ziegler Walsh Stanton & Romano, LLP. She focuses on the area of Workers’ Compensation, having helped thousands of injured workers navigate a highly complex system and obtain all the benefits to which they were entitled. Ms. Stanton has been honored as a New York Super Lawyer, is the past president of the New York Workers’ Compensation Bar Association, the immediate past president of the Workers’ Injury Law and Advocacy Group, and is an officer in several organizations dedicated to injured workers and their families. She can be reached at 800.692.3717.

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Cost Shifting: Worker’s Compensation Dirty Little Secret

Today’s post comes from guest author Thomas Domer, from The Domer Law Firm.

Today I taught worker’s compensation “Offsets” in the course I teach at Marquette Law School. The students were aghast at the amount of “cost shifting” that occurs in worker’s compensation: that is, medical costs paid by a variety of sources other than worker’s compensation for medical expenses that should be paid by the worker’s compensation insurer.

We all pay an additional price for medical costs borne by group health insurance carriers, Medicaid, and Medicare that should in fact be paid by worker’s compensation insurers. This “cost shifting” occurs in two significant ways. First, if the claim is denied by the worker’s compensation insurance carrier, medical costs may be paid by the worker’s group health insurance or other private insurance company, or through State Medicaid or federal Medicare programs (the cost of which we all pay in taxes). When those claims are settled, the worker’s compensation insurer routinely saves money by reduced negotiated payment contracts with medical providers, between the provider and the group health carrier, Medicare, or Medicaid (rather than the “full boat” payments that should be paid by the worker’s compensation insurer). If the treatment is deemed work-related after a hearing, the worker’s compensation insurer will pay the other insurer, but at reduced rates.

Second, since only about one in ten cases involves any kind of litigation, workers who are not represented routinely bill their group or other insurance carrier for medical treatment that should be paid by worker’s compensation. Bolstering this notion is a recent article in the Insurance Journal. In the article Jonathan Gruber, Professor of Economics at M.I.T. was quoted indicating that worker’s compensation carriers should see fewer claims as a result of more Americans obtaining health insurance under the Affordable Care Act. He said “As more people have health insurance there is less need for them to have injuries covered by worker’s compensation and this should lower worker’s compensation costs.” Nowhere in this analysis is the notion that the appropriate payor for a worker’s compensation injury should be a worker’s compensation insurer, not health insurance premiums (which are shared by us all) nor Medicare and Medicaid (again shared by us all in the form of taxes).

Workers hurt on the job should have their medical treatment paid by the worker’s compensation insurer, who has received a premium for that risk from the worker’s employer. Cost shifting may increase worker’s compensation profits, but it hurts both the employers’ and the employees’ bottom line.

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Medical Care Politics in Worker’s Compensation

Today’s post comes from guest author Thomas Domer, from The Domer Law Firm.

The mythology surrounding employee fraud in worker’s compensation is pervasive. Many of my clients begin their conversations with me indicating the following: “I’m not one of those folks faking their worker’s compensation claim.”  The exaggerated media publicity concerning employee fraud has also resulted in outright worker intimidation regarding filing a claim. I had this conversation today with a prospective client.

Attorney: Why didn’t you report the incident?
Client: I didn’t want to have that on my record.  Nobody will hire me if I have a worker’s comp injury.
Attorney: Why didn’t you seek medical treatment?
Client: I do not have insurance.
Attorney: Can you obtain insurance under the Affordable Care Act?
Client: You mean Obamacare?  No way!

Fear of being stigmatized as a complainer, whiner, or simply a recipient of worker’s compensation benefits has prompted many legitimately injured workers from filing a worker’s compensation claim.

The adverse publicity concerning the Affordable Care Act (and its pejorative popular name “Obamacare”) results in many otherwise qualified workers from obtaining the health care they need, especially when denied by a worker’s compensation insurance carrier. 

The politics of medical care intrudes in the worker’s compensation arena daily.

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Superstorm Sandy: How To Be Compensated For Your Damages

Pasternack Tilker Ziegler Walsh Stanton & Romano LLP hopes that you, your family and your neighbors are safe. As we work through the Hurricane Sandy recovery process we want to make sure that you have important information on what steps to take in order to be properly compensated for any damage to your home and/or business.

Property Insurance Claims

Superstorm Sandy Property Insurance Claims

We urge homeowners who have experienced property losses from Hurricane Sandy to file insurance claims with their insurers promptly.

  • Document losses as best as possible through both photos and videos before cleaning up damage.
  • Make only necessary repairs to prevent further property damage, like covering broken windows. Permanent repairs should not be made until after the insurance company does an inspection.
  • Write down your claim number and keep a log of all your conversations with your insurance agent and claims adjuster, including their names, dates and visits and calls.

Business Interruption Claims

Superstorm Sandy Business Interruption Claims

If you have suffered any business interruption as a result of the storm, you should also contact your insurance company promptly and inform them of your losses.

  • Documents the losses as best as possible through both video and photo evidence before clearing the damage.
  • Document all of your business losses with your accountant.
  • Contact us for your free evaluation to determine whether your claims are covered by your insurance.
  • If you claim was denied or if you were underpaid, call us for a FREE evaluation of your claim

Call Us Toll Free

(855) 2-STORM-LAW

(855) 278-6765

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Alternative Security Program Changes Collateral Rules

California’s self-insurance program is innovative

Today’s post comes to us from our colleague Jon Gelman from New Jersey.

Christine Baker, director of the Department of Industrial Relations (DIR), today approved the implementation of the 2012/13 Alternative Security Program (ASP), freeing $6.17 billion in capital, giving self-insured California businesses greater financial flexibility.

The ASP is a first-in-the-nation, innovative program operated by the non-profit California Self Insurers’ Security Fund with the California Department of Industrial Relations. The program provides guarantees to replace security deposits required to collateralize self-insured workers’ compensation liabilities.

“Self-insurance and the ASP are innovative ways that California can support businesses and help them reinvest capital back into growing their business,” said DIR Director Christine Baker. “With workers’ compensation representing a major expense to businesses, this program benefits both the businesses and the larger California economy in a meaningful and positive way.”

All employers in California are required to have workers’ compensation insurance to protect themselves and workers and minimize the impact of work-related injuries and illnesses. Meeting this requirement can be accomplished either by buying an insurance policy, or through obtaining authority from the DIR Office of Self Insurance Plans (OSIP) to self-insure the businesses’ workers’ compensation liabilities.

“I’m surprised that there are not more employers taking advantage of self-insurance,” said OSIP Chief Jon Wroten. “While there are standards and requirements that must be met, for employers with sound risk management practices the benefits can be substantial to the firm’s bottom line.”

Traditionally, self-insured employers are required to maintain a deposit to collateralize their risk in the amount equal to 135 percent of estimated future Liability. This deposit, which is cash, irrevocable letters of credit, securities or surety bonds, limits the employer’s ability to use the cash or credit line to expand their business. In contrast, ASP members can apply that cash or line of credit back into their businesses while the ASP assumes responsibility of the security deposits.

California currently has 7,952 employers protecting more than 4 million workers representing a total payroll of $173 billion through self-insurance workers’ compensation plans. One of every four California workers is protected by a self-insurance plan.

Self-insured employers in California represent large and midsized private companies, industry groups, and public entities such as city, county, state and school districts.

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