Worker's Comp 101 - System Participants PDF

Worker’s Comp 101 A“30,000 foot view” System Participants + Commonalities & Differences of WC system among states  Part 1: System Participants  System Participants We will focus on 5 different groups, all with different goals & needs. Some of these tend to be...

Worker’s Comp 101 A“30,000 foot view” System Participants + Commonalities & Differences of WC system among states  Part 1: System Participants  System Participants We will focus on 5 different groups, all with different goals & needs. Some of these tend to be adversarial in nature & application. The five categories of system participants are: 1) Claimants 2) Health Care Providers/Medical Practices 3) Attorneys/Law Firms 4) Insurance Carriers 5) “Others”  1. Claimants AKA what SHOULD be the foundation of all WC systems - Will ALWAYS be the focus of our efforts, and the efforts of other system participants - Known as “patients” for medical providers - Known as “clients” by attorneys - The most common body parts injured are: Lower Back Area (15.5% of claims), Multiple Body Parts (14.4%) Wrist & Hand (14%), Ankle & Feet (10.4%) & Knee (8.3%) - Average claimant is typically male, between the ages of 35-44 - Average claimant is the “bread winner” of the family  2. Medical Providers/Medical Practices - There are multiple types of medical providers (potentially) involved in treating any WC claim - A patient can see multiple medical providers for the same injury/WC claim - In some states, claimants have limited or no choice in choosing their own WC medical provider - Trend in many states is for fewer medical providers to be involved in the WC system - Medical provider can provide either direct treatment, or evaluation services - Some states make finding data on medical providers/WC claims available via public records request (like TX)  2. Medical Providers/Medical Practices (continued) Every WC system will have the following types of Health Care Providers A) Urgent Care/Family Practice (initial treating provider) B) Orthopedic Surgeons C) Neurologists D) Neurosurgeon E) Psychiatrists F) Pain Management/Physiatrist G) Chiropractors H) Physical Therapists I) Evaluations (Peer Reviews, RME’s & IME’s) J) Psychologists/LCP’s K) General Surgeons L) “other” specialties 3. Attorneys/Law Firms - There are two types of law firms in WC claims: Claimant/plaintiff attorneys (our “side”) & defense attorneys - Are sometimes the “driver” within a WC system. For example, this is true in PA. It’s not true in TX - Often supplement their WC business with social security (SSI) claims & Personal Injury claims (PI) - Are often difficult to access, because they are in hearings - Rely heavily on staff to process WC claims (paralegals/legal assistants) - System participation varies from high (PA) to very low (TX) - Typically represent severely injured clients, which often means more medical care is necessary (including prescriptions ) 4. Insurance Carriers - Are contracted to “cover” the expenses associated with a WC claim - Potentially are “on the hook” for medical care costs + lost wages (indemnity benefits) - Costs are trending down (for both medical & indemnity costs) in most states - Every state has an insurer of last resort and also has a guarantee fund (they're different things) - Employ adjusters, who “manage” WC claims - Interests are minimizing costs, which unfortunately often leads to minimizing WC claim value - We often have an adversarial relationship with them  5. “Others” (and which side typically utilizes them) - TPA’s (third party administrators, like Sedgewick) (carrier) - PBM’s (Pharmacy Benefit Managers, like OptumRx (carrier) - Evaluation Medical Providers (like Peer Review MD’s/DO’s/IME’s/RME’s/UR’s) (carrier) - Expert Witnesses (both sides, depending on the state) - Unions (stronger in PA, very weak in TX)(claimant) - Additional 3rd parties (Nurse Case Managers)(carrier) - Employers/Non-Subscribers (TX only) - Self Insureds  Part 2: Commonalities & Differences of WC system among states  Commonalities - In every state, the claimant is entitled to medical treatment & lost wage replacement. Amount for lost wages varies depending on the state’s system & whether the claimant is a high wage earner - Each state has a state controlled administrative arm/group that administers the state WC system - Each state has a process to resolve disputes (know this from the perspective of each system participant - Each state has an outlet to punish bad behavior by system participants (usually fines) - Every state requires WC coverage (with some exceptions), EXCEPT for TX - A “grand bargain” is struck between making sure employee is taken care of financially (lost wages) + medical treatment in return for giving up the right to sue the claimant’s employer  Differences - Amounts of overall benefits awarded will vary between state WC systems - Networks/Panel medical providers (limits choices for claimant) - Court system/legal system vs. administrative system - How well the “grand bargain” holds up depends on which state you’re in - Which system participant “drives” the system depends on the state. For example, in Texas, medical providers drive the claims. In PA, its attorneys. - Impairment Rating system (which edition is used) - Treatment guidelines, or lack thereof - Drug Formularies, or lack thereof - Lifetime medical care (in theory) vs. the ability to “settle out” future medical care + lost wages - Exclusions vary  Questions & Discussion Do you know what your state’s department is named, and where to find it online? Budget an average of 30-60 minutes per day to research your state WC system. IMMERSION is the key! Knowing your system participants needs (in general & also related to WC prescriptions) allows you to better serve those needs. You can find all the resources you’ll ever need in SharePoint. Check out the “EZ Scripts University” section- it’s organized by subject Area.