The workers compensation system is the last bastion of medical cost shifting in the United States An employee benefit program typically contains one or more aggressive cost containment techniques designed to curb rising group medical costs. So how does the healthcare industry recoup this income? You guessed it – through the workers compensation system. As a result, worker injury medical costs are catching the full weight of increases in healthcare costs – and there is no end in sight.

 

To make matters worse, in many state jurisdictions employees can go to any physician they want, making it very difficult to direct the employee to the most cost effective medical service. As a result, your organization will often lose a high degree of control over the quality and delivery of healthcare to the injured employee. In addition, without proper communication between your organization’s Claim Coordinator and the claim adjuster vital information will not be shared with during the first 48-hours of an injury and the organization’s temporary duty program will not be implemented properly. This lack of communication can drive workers compensation costs through the roof.

 

Also, the Family Medical Leave Act (FMLA) and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) impose on the organization potentially strict guidelines on what information can be obtained and how it can be obtained. Many healthcare providers are struggling with compliance of HIPPA in particular and have established very conservative standards as far as what medical information will be released to the organization about an injured employee’s condition. Understanding these laws and knowing how to comply with them in the context of a worker injury can be extremely challenging for the claim management team as well.

 

Finally, many healthcare practitioners do not understand the workers compensation system. They are well trained in diagnosing an employee’s injury and prescribing the appropriate medical care. However, they often struggle with such things as:

 

  • Working with the employer to develop an ADA-compliant accommodation strategy that will get the injured employee back to work as soon as possible;

 

  • Understanding the “essential functions” of the job the employee performs and putting this in the context of return-to-work strategy;

 

  • The impact that “balance billing” has on the employee’s attitude towards their employer;

 

  • The need to communicate frequently with the Claim Coordinator and claim adjuster throughout the process of employee healing;

 

  • Understanding the different classes of disability and what they mean to effective claim management.

 

  • Understanding the regulatory process associated with workers compensation claims and where they fit into it.

 

In short, while the workers compensation system can be extremely lucrative to the healthcare system it also is a challenge. As a result, many healthcare practitioners have difficulty interfacing with the Claim Coordinator and claim adjuster as they manage and eventually setting the worker injury claim.

 

It is recommended that your claim management team develop and use a checklist to evaluate medical providers situated in its local area.  It is also highly recommended that members of the claim management team tour the health provider’s facilities as they complete this survey.

 

In addition to the scope of medical facilities there are nine key topics that must be discussed in great detail so that there are no misunderstandings:

 

  1. Professional staffing to satisfy expected scope of injuries.
  2. Facilities.
  3. Occupational medical services provided.
  4. Additional services provided if needed.
  5. Communication flow and expectations during the course of injured employee recovery.
  6. Education and training facilities.
  7. Medical discounts provided.
  8. Privacy standards.
  9. References.

 

The claim management team should take its time in discussions with medical providers. There should be no mystification as to how medical services will be delivered. Remember that poor communication with medical providers can directly short-circuit the organization’s claim management process.

 

For a free copy of CompEraser’s checklist titled “Occupational Medical Facilities and Services Checklist” please email us at info@comperaser.com.

 

For more information on our patent-pending claim control services that provide resources to address all the above issues, plus much more, we invite you to visit our website at www.comperaser.com.