Doctors to a certain extent run their practice they way they want to, as they can choose the types of cases they take and use different methods for different patients. However, they also have to play ball, so to speak, with a number of different regulators.
From being approved to working with a certain insurer to keeping their medical license, they have a lot to consider. We'll look at how workers compensation plays out for them.
State to State
There is a lot of misinformation out there about how doctors treat workers compensation patients, and much of it has to do with the fact that each state has their own rules. For example, in California a worker can have their regular doctor treat their injury if they had their own health insurance at the time they were hired and if they had already told their employer about their doctor before being injured.
In other states, the employer may choose the doctor as a way to ensure there is no fraud or the worker may be able to choose any doctor that's in their network.
Insurance and Billing
A doctor has to follow a very complex set of rules should you go to him or her with a work-related injury, and the billing gets confusing quickly. Though a patient can typically go to any doctor as the very first consultation (or the ER should it be deemed necessary), a doctor may refer them to someone else for additional treatment.
Also, in certain states it may be possible to receive care from a PA or an RN for treatment while in other states one may be required to see an MD or DO, and the care may be limited. Say a worker has chronic back pain (to take one of the most common scenarios of injury), and they want to see a specialist like a chiropractor or massage therapist for relief. The insurance may cover only a few sessions at most.
Finding a Doctor
As an employer, it's easy to want to use all the power that you have available to you. In many cases if you live in a state that allows you to make the decision, it makes sense to find a doctor that will be fair to your employees, but who will never recommend treatments they don't need. Ultimately this should lower your insurance and make you less of a risk.
However, it's also worth noting that when a doctor doesn't have a history with a patient, they're liable to make mistakes. Those mistakes could very well leave you liable to additional compensation if something goes wrong and the worker never fully recovers.
Every day you likely see people make decisions you wish they would reconsider. People make mistakes because they're tired, bored, angry or just plain uninterested in what's happening around them. Appeals were made for those who feel the courts were full of professionals making choices based on their own self-interests and not based on the facts.
We'll tell you what you need to know about workers who choose to go through the appeals process.
Before You Reach the Courts
If a doctor denies a request for treatment that an employee feels is necessary, the first step is to get a second opinion. Often this can be done through a Qualified Medical Examiner, meaning this person has undergone special training to work with injured patients on the job. However, if an employer refuses to acknowledge their part in the matter or the insurer denies their responsibility in the claim, then it may be necessary to take the matter to the courts.
How It Works
For some cases in workers compensation, the employer is clearly at fault, they cover the employee's injuries and insurance picks up the tab. However, other times the facts aren't so clear and the employer goes to court. Workers compensation will typically have their own judges who work to decide fair outcomes for all employees they see.
They look at the testimonies of the employee and potentially the employer, they'll gather the medical information and review all other evidence to determine what compensation should be given. Once the judge gives their decision, either the employee or the employer may appeal. In New York state, it's normally 30 days after the filing, but each state will have their own specifications.
The appeals board typically will then have the power to modify the terms of the decision, or flat-out agree or disagree with the judge. If those on the Appeals panel don't agree with each other, it will get kicked up to a higher level for a full Board review, in which case there will be another set of people who look at the facts.
Benefits and Beyond
You are not required to pay benefits while a case is being contested, meaning that some employers have used it to tie up funds by dragging cases out through appeal after appeal. The justice system is somewhat malleable in that cases have the ability to be pushed up the ladder until they reach the very top — especially in unique cases that haven't been tried before. If you're at a loss of what to do, remember that there are always options. However, the legal costs and hassle may not make it worth it.
The Annual Workers' Compensation Educational Conference (WCI) is just one example of how complex this topic is to everyone involved, from doctors to employers. Many of the sessions are made solely for those in specific industries (e.g., only for judges or attorneys.)
With a variety of laws from state to state and interpretations of those laws from state to state, this conference has to address a lot of questions and confusions. We'll give you an idea of what it was like to attend, though it should be noted that it's impossible to cover it all here.
All Eyes on Florida
The Florida Supreme Court has already ruled on several aspects of the workers' compensation rules, as in they will not be limiting attorney fees and temporary employment benefits, in an effort to avoid needless litigation from employers. Some experts say this has worked with fewer court cases being heard, but insurance companies are claiming that they're now subject to paying the costs and haven't been able to set prices for their premiums based on these laws. They now want to raise their rates up to 20%.
Florida is where the event was held, so it was a topic that was especially on people's minds. Between this and the contrasting event of falling costs of rates in Oklahoma, it was these two states that won the spotlight. Everyone at the conference wanted to fight against fraud and waste, but the best ways to regulate that is still debated by many.
Bureaucracy, Advocacy and Safety
These are typical topics when it comes to anything related to workers' compensation, but the conference attempted to address them with a modern bent. For example, studies into the Affordable Care Act (Obamacare) have not necessarily shown the rates to have changed due to the laws, though it behooves employers to keep an eye on any overlap between provider networks and approved workers compensation professionals for additional cost savings and streamlined care. They also talked about the employees who are not covered by workers compensation (e.g., domestic or agricultural workers.)
There was more information about how employers can better develop their own safety plans, and how changes in healthcare will affect the program. The conference addressed how many larger businesses do not have effective risk management, and how accountability should be at the forefront of each business.
There was an emphasis on how data can help people make better decisions, and on how best to use that data when it comes to driving change in workers compensation. In other words, there was a lot happening at this conference, and if you want to learn more about a particular talk you can click here.
With every state having their own workers' compensation rules, it has meant that incentives have varied widely throughout the nation. The majority of doctors, lawyers, insurance carriers, employers and employees are all either inadvertently or consciously trying to avoid their losses at every level.
When a report came out about surgery and Medicare in the nation, it was found that New York was performing vastly below the average while Alabama and Louisiana were operating at far higher rates. Is it that because people in Alabama are more likely to become severely injured? It is a better bet to say that there are other forces at work here. We'll look at the numbers from the 33 states that were included in this study, and talk about the implications of it for you.
Averages and Rates
As you might expect, states without fee schedules had much higher utilization rates than those who did (up to 150% over the average amount.) This means that if there was a limit on how much could be spent, somehow that limit was magically reached in the majority of cases. Surgery and other costly procedures were performed sparingly.
If there was no limit, there seemed to be more care that was necessary to complete the treatment. The same trend was shown whenever there were states that had some type of limits imposed, whether it was percent-of-charge or cost-to-charge.
What Does This Mean for You?
There are several ways you can look at this study. One is that you could assume those who did receive more care got the additional consideration because there were no limits in their state. A doctor had every measure to complete a full plan for their patients without having to worry about costs thus achieving a better state of wellness for the patient. This is certainly one reason why no limits might be imposed in a state. However, the less optimistic viewpoint would be that people are flat-out exploiting the system.
Certainly we know that fraud is real in workers compensation, and potentially difficult to reveal. Whether a doctor recommends one unnecessary treatment for one patient or 50, they're committing an act that will raise everyone's costs further down the line. If you're interested in becoming an advocate in your state, you may want to lobby your local lawmakers with information about recovery and relapse in patients in the states that have imposed limits. It is the best way to prove that those who have limits are both not a drain on the system while still achieving acceptable care. This is a difficult issue to talk about, but one that needs to be addressed.