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.
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| 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.
Or care...
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...
If we're going to promote the good in the industry, then we also need to expose the bad.
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.
Outstanding blog post, thank you
ReplyDeleteThanks David. That's also the view from the Injured Worker perspective. Those 'foxes watching the hen house' might be better relocated to the State or Federal Penitentiary systems.
ReplyDeleteMany injured workers would like to see Congressional investigations, indictments and proper trials... for what appear to be RICO and basic FRAUD violations and worse as a pattern of practice by profiting parties. I would like to see local and national investigations, that's for sure.
They could even start with my case....and follow the money. It could be explosive. Big players. Mean crowd.
One of these days, could you also tell your readers about FEHA and the Interactive Process and how it can be life saving for injured workers??
After more than 2 5 years waiting for medically necessary treatments. ...authorizations are finally trickling in. Hooray. : /
Yep
Delete1 OF 2 COMMENTS: Thank you Mr. DePaulo for this article. The lives of many injured workers are devastated by the terrible things that the defense is willing to do to the injured worker.
ReplyDeleteYesterday, I read another article by Cathy Albisa of Palm Beach, FL. In it she sights that 10 years ago, she interviewed an injured worker who told her his / her experience in a workers comp claim. She states, "The abuse faced by injured and ill workers needs to come out of the shadows and receive the attention it deserves. Ten years ago, I sat down for my first interview with an injured worker. That worker told me a story so outrageous and convoluted that I worried about his mental health. But, as I continued to interview workers, more than 100 injured workers that year alone, we heard similar stories of abuse over and over again."
She doesn't specify the particulars of any of the stories and experiences. I can only imagine what these souls have been through and may still be going through. As you know, I am an injured worker and I have been forced under anesthesia twice against my advanced requests / directives. At my 3rd epidural procedure, I was brutally forced under anesthesia. Each time I awakened with injuries / maiming in other parts of my body and injections in much of my person that were not a part of the ESI procedures. Too boot, I have experienced bizarre circumstances with Doctors, medical providers, hospitals, etc. All that I am sure was designed events to call into question my mental health should I file complaints for each happenstance. Interestingly, the AME in my case, after I demanded to see him again since I realized that I was being harmed on purpose, sights "ongoing psychological problems". For the record, I haven't any previous psych issues in my medical history. However, it has been suggested that I add a psych claim to my case. I would imagine that a psych claim would seal the mental health issue for the defense, thereby calling into question my credibility. I have discovered that surgery reports have false information documented in them, forms / documents that I signed have been altered with false info over and above my signature. Even the anesthesia form with my signature has the incorrect box checked for the 3rd epidural. When I signed the face page of that multiple copy form, it reflected "Local Anesthesia" pain blocker. I never agreed in writing to monitored or general anesthesia at the 3rd epidural. When I left the surgery center for the 3rd epidural, I was handed a copy of the anesthesia form with my signature on it that indicates "monitored anesthesia".
I can only imagine what these other injured workers have endured that survived. I say survived because I have shared my experience with other injured workers, I was told that I am lucky to be alive, they could have killed me. I'm told that the biggest money looser for an insurance carrier is back injuries.
What has happened to me and other injured workers is a well-orchestrated effort on the part of many people, including but not limited to medical providers, medical businesses, not just the Ortho Surgeon. For example in my case, the medical director at the 3rd surgery center was my anesthesiologist. He did nothing to protect me, the patient, in his surgery center. In fact, he participated by allowing the crime to take place in his surgery center.
2 of 2 comments: After the 3rd epidural, I demanded to see the AME again, he then diagnosed me with degenerative disc disease, less than a year after his first report wherein he told me, that I didn't show any sign of DDD. I was told by the AME's legal staff that my 5 page letter describing to him some of the chain of events and how I kept getting hurt and much more, was removed from his file for my protection, as it was "exparte". I don't believe it was removed for my benefit, I believe that it was removed because it specifically set forth some of the crimes committed against me and the chain of events. I am told and have read, that he, the AME, had an obligation to report the wrongdoing or suspicion of wrongdoing. Instead, his report calls into question my mental health and has no reference to what I verbally told his historian on the phone and in the 5 page letter. The AME would not allow me to have a "patient advocate" with me during his evaluations either. In fact he refused to do an evaluation and left the room. Granted, my patient advocate was my sister.
ReplyDeleteI am hoping to get a mandated disclosure to benefit injured workers. That would include the right to a patient advocate, the right to have any medical evaluation with an AME, QME, IMR and any medical appointment with a medical provider of any kind including the patient’s primary treating physician - video and audio taped. In my case, it was the primary treating physician who either maimed me or set me up to be maimed during the 3 ESI's.
There is no doubt that a major part of the strategy behind my and other injured workers experiences is to destroy the patients credibility by having them sight the outrageous and malicious things that are happening to them since they filed their WC case. I hope that the good people of workers comp will stand up for the souls who are regularly abused in the workers comp system.
1 of 2 Jeffrey Stevenson, M.D.
ReplyDeleteINDEPENDENT MEDICAL REVIEW ORGANIZATION (IMR) decision.
A UR physician and a follow-on IMRO radiologist denied complete imaging for STAT MRI and CT for possible early surgery for possible scapholunate disruption and scaphoid fracture that had a 3 week post injury window for repair. The UR and IMRO delayed the imaging and the window for optimal repair was lost.
There were 5 Red Flags on this case missed by the UR physicians.
THE CASE
1-4-2013 DATE OF INJURY
1-4-2013 DATE OF INITIAL PRIMARY MD EVALUATION:
58 yo worker fell and injured his left wrist.
He was seen same day and x-rays were ordered by the evaluating physician.
The plain films were negative, but the physician was concerned and referred him to a hand surgeon.
1-8-2013 ORTHOPEDIC SURGEON EVAL AND REQUEST FOR STAT MRI AND CT WRIST
The hand surgeon saw him within 4 days and ordered STAT wrist MRI and CT and was concerned he may have a scaphoid fracture and or a scapholunate ligament tear and may need surgery and apparently noted a 3 week surgical window for repair.
1-18-13 INITIAL ADJUSTER-UR DENIAL
1-25-13 3 WEEK WINDOW FOR SURGICAL REPAIR CLOSED
1-28-13 IMR APPLICATION RECEIVED:
IMRO REQUESTED AND WAS GRANTED A TIME EXTENSION ON THIS EXPEDITED APPEAL
IMRO radiologist reviewed this case and authorized the MRI and denied the CT noting the hand surgeon should wait and see what the MRI showed then request the CT.
The IMRO radiologist had noted the fact that that the repair within 3 weeks of the injury was important.
2-5-13 IMRO APPROVED THE MRI:
2-5-13 IMRO DENIED THE CT:
STAT PREOP WORK-UP STILL NOT COMPLETE
ESTIMATED ADDITIONAL TIME TO DO THE STAT SURGERY:
These are optimistic estimates.
10 days to schedule the MRI and see the patient and check MRI.
3 days for new CT request with dictation to insurance carrier-UR
10 days for STAT UR to review and authorize the CT
(This is the time for the initial UR evaluation).
5 days to get CT scheduled and see the patient back again.
3 days to request surgery with dictation.
10 days for STAT review with UR.
3+ days to get into surgery.
_____
44 days ADDITIONAL TIME FOR WORKUP
31 DAYS TO GET IMRO MRI AUTHORIZATION
_____
75 DAYS TO GET TO SURGERY ESTIMATED
COST OF IMAGING (the highest prices I could find in the OMFS)
$521.91 MRI WRIST 73221
$307.58 CT WRIST 73220
$160.00 RADIOLOGIST READ AND REPORT
_______
$989.49 TOTAL IMAGING COST
WPI MAX 39%
(36%+3%pain add-on,Table 16-18,Page 499,AMA Guides,5th Ed)
TEMPORARY TOTAL DISABILITY ADD-ON TO GET TO SURGERY
$9,000 = 10 weeks @ $900.00/week
PROBABLE 2 years total TTD
(Salvage surgery, poor result, physical therapy, pain management, revision surgery, pain management)
$90,360.00 = 104 weeks at $900/week
$150,000 COST OF CARE
Surgeries, PT, meds, pain management (no FRP)
$100,00 RESERVES
__________________
$340,360 TOTAL including reserves
Poor result, arthritis with chronic pain, depressed
marginally employed, no longer paying taxes or union dues.
______________________________________________
THE OTHER WAY IT COULD HAVE GONE:
1-4-13 DATE OF INJURY AND FIRST EXAM
1-8-13 DATE OF HAND SURGEON MRI, CT REQUEST
1-8-13 DATE ADJUSTER WITH STAT PHONE CONSULT AUTH'd
(Hard staff push for STAT care)
1-12-13 DATE FU MRI, CT REVIEW AND SURGERY REQUEST
1-12-13 DATE ADJUSTER AUTH'd SURGERY BY PHONE + FAX
ADJUSTER HAS UR CONSULTING SURGEON WITH EXTENSIVE TRAINING.
1-13-13 SURGERY DONE
7-13-13 6 MONTH POST OP DECENT RESULT,
RETURN TO WORK
P+S
7% WPI
MINIMAL FUTURE MEDICAL AND NO MEDS
TEMPORARY TOTAL DISABILITY
$23,000 = 26 weeks @ $900/week
$30,000 = Cost of care, surgery x 1,PT,Meds
(No pain management, no FRP)
$15,000 = RESERVES
________
$68,000 = TOTAL including reserves.
Decent result and return to work gainfully employed
2 of 2
ReplyDeleteDISCUSSION
Falls and sprains generally do not come in the same day unless they are serious.
Red flag #1.
The initial evaluating physician on the date of injury was concerned enough that he immediately obtained x-rays and apparently clinically by history of how hard the fall was, the level of pain, and exam findings he was concerned that there could be a fracture, serious disruption or derangement that needed STAT specialty surgeon care.
Red Flag #2
The surgery consult may even have been done without authorization due to the 4 day speed with which the patient was seen by the hand surgeon.
Red Flag #3
The hand surgeon evaluated the patient and was also concerned that there was a serious derangement and depending on the type of derangement the patient may need STAT surgery.
Red Flag #4
The "3 week surgical window" to try for a good surgical result noted by the IMRO radiologist warrants commensurate speed for review.
Red Flag #5
Few doctors with experience taking care of these injuries take them lightly.
The IMRO radiologist cited the importance of early surgery then disregarded his own citation in his decision.
The treatment should have been immediately authorized.
The Medical Board review can be funded by the insurance carrier payments the same way they fund the IMR. The Medical Board can select a panel of specialists that may confer and render decisions.
Physicians reviewing cases for the Independent Medical Review Organization (IMRO) as well as regular UR physicians need to be answerable since insurance companies are using opinions from these practitioners to make decisions regarding how medicine will be practiced on the patient.
In turn the insurance company may hold the vendor responsible for not providing a capable physician.