As you know I've been on a kick lately about professionalism in the industry and recognizing the good we do.
Then I get an email from a former claims professional turned auditor that completely deflates my enthusiasm and makes me angry.
The emailer has been in the process of auditing some cases on behalf of an insurance carrier whose cases are administered by a Third Party Administrator.
This is a pretty typical arrangement. Carriers are very good at "writing the paper" and all the processes involved from brokerage administration to determining the risk (underwriting) and marketing. Then the job of actually handling the claims gets outsourced to specialized companies: TPAs.
The auditor writes she's appalled; outraged at the lack of any sense of urgency, the lack of responsiveness to defense attorneys, not to mention applicant's attorneys.
She's astounded at the failure to pay temporary total disability, the failure to advance permanent disability a year after the Agreed Medical Examiner's findings are undisputed to a person who's getting $500.00 a month from Social Security.
She's offended that the TPA lets the defense attorneys handle the files, lets cases linger until a pinky finger from 2008 ends up turning into hand, arm, neck, back, internal, sleep, psyche, etc., etc. - on a case that was really ready to settle no less than 4 years ago.
|Yes Bowzer, it DOES stink...|
She asks, "Why would these cases still be open (excluding those with obvious complex if not catastrophic issues) when the file reflects many opportunities for settlement that slipped away?"
Of course she also notes that the TPA, with its own Utilization Review and Bill Review service company has made as much as $50,000.00 in bill review charges on a single file.
$50,000 reviewing bills of it's own Medical Provider Network physicians and vendors.
MPNs have established fees by contract. There is no need, no reason, nothing to justify reviewing and then discounting your own provider's bills.
In the meantime, non-MPN providers, who more often than not shouldn't even be paid (how about an objection letter - a completely foreign concept it seems) will be paid at fee schedule or some percentage of the same at the end of a case where the claim had been entirely denied for lack of compensability.
It appears after all that it's not just the injured workers, their attorneys, and their doctors responsible for the high costs associated with California work comp, but perhaps to a greater extent, those foxes left to watch the hen house, sucking out undeserved, perhaps illegal, and definitely unethical, revenue from the system while nobody even seems to notice.
She says, and I agree, that something's wrong with this picture, when there are $65,000.00 in expenses between defense attorney costs and bill review, etc., on a case where the applicant got a total of $26,000 in TD and PD via a Compromise and Release of the case.
She asks, "What do you think?"
So here's my answer - I think this is bullshit.
These are the kind of actions that take faith out of the system, creates mistrust, harms people, destroys lives.
Because some assholes have can't regulate their own greed.
And what is the penalty to the TPA that allows this misconduct and lapse in ethics and morals? Maybe some penalties, but probably not enough to quell this lack of professionalism and bad behavior. And if they lose the contract with that carrier, there will be others...
But here's the tough part - anyone that steps up and calls the spade gets blacklisted and ostracized, and will never work in this industry again, or perhaps anywhere.
Those seeking to do the good job and do the right thing end up crushed by the same system that destroys the lives of those for which it was created.
So here's my challenge to the leaders of those companies, the TPAs, the carriers, and every single vendor out there: create and enforce a "no consequences" forum. Names, dates and actions should be exposed with no consequence to the whistle-blower.
If YOU as an industry leader are truly about maintaining the highest standards, promoting work comp careers, seeking the best people, then there must be a mechanism for reporting on ourselves to shed the unethical and immoral.
Our failures will be the industry's undoing.
I'm all for celebrating the good that we do.
And frankly we need to castigate those that foster ill upon others.