Monday, March 16, 2015

Always Right, Until Wrong

Ask my wife - I'm always right.

Except when I'm wrong.

Then I admit I'm wrong, and ... I'm right again!

So, I admit I'm wrong.

Friday I admonished the California Division of Workers' Compensation to "do your job" and fine all of the insurance companies and third party administrators (and collect those fines) that fail to adhere to statutory time limits for getting records to Maximus Federal Services for Independent Medical Review.

Based on a spreadsheet of such failures from Maximus, there are a lot of them, and not just minor delays but significant failures.

I assumed that it was the carriers and TPAs that were the cause of these delays and failures because the Maximus spreadsheet identified 5,021 cases on which records are at least 90 days late by entity, number of average days late, percent of cases that are late and the number of records requests that are late.
Bowzer admits he was wrong...

You know what they say about ass-u-me...

Turns out that many, if not most, of these issues may actually be the fault of Maximus.

Jerry Azevedo, spokesman for the Workers' Compensation Action Network, told WorkCompCentral that most claims administrators have submitted records as required, but Maximus has not been able to match them to the case.

And comments posted by claims adjusters to the original WorkCompCentral story on Friday mirrored that opinion.

Said one commentator: Our company gets about 10 notices a month from Maximus stating we did not provide the medical records that were requested. We are able to demonstrate immediately to Maximus that we have already sent them and they have just failed to match the records with the Maximus case. We ship everything via overnight so we have tracking mechanism in place to verify they received them.

And another stated: We also get notices from Maximus that the records were not received, but when we check, and re-produce the documentation, they have had to retract their letters and concede that they did, indeed get them. Another issue that we have is with Maximus telling us that we have not paid their invoices. Here again, we send proof, and never hear another word.

And another: I work for one of the biggest TPA's. I can say for CERTAIN Maximus loses many of the IMR records sent to them. Because of our size, we get huge lists of alleged non-responses to NOARFI's and of the last 50 all were complied with timely except 1-2 were missed by Examiners. Of the others, half were sent (and disappeared), or NOARFI's never received (our mail is imaged by a third party so no chance mail was "lost"). We have numerous cases where they were sent TWICE and they still claim to have not received. And the billing: we just got a list of alleged non payment of IRM billings of the 55 alleged, in 52 of those NO BILLS were ever sent! They are having serious issues and the injured workers are paying the price, not the claims admins.

Maximus tells WorkCompCentral that it has provided all information it is contractually obligated to provide to DWC and that any questions about how the company is administering IMR should be directed to DWC.

That's a ridiculous position to take - Maximus knows whether it is compliant or not; that it won't admit that is even more ridiculous. In a civil proceeding when the accused takes the 5th Amendment against self incrimination the jury is instructed that they may infer guilt...

Maximus is a multi-billion dollar company, and despite all those resources the story seems to be that they can't seem to get a pretty simple data management issue resolved. This isn't rocket science. Hell, it's not even medical science or computer science - it's pretty basic records management.

Unfortunately people contacted for the story at DWC did not comment prior to story deadline.

But here's the rub - if DWC is relying on Maximus data, and Maximus is relying on DWC data, it seems that the perpetual circle of inadequate data means that nobody really knows what's going on, or is willing to tell the truth.

That's even worse than just blaming recalcitrant carriers...

So, either there really is a blatant disregard for the system by rogue carriers and TPAs, or Maximus really is incompetent at matching records to cases, or DWC really has no clue as to what the real situation is, or a combination of some or all of these (and perhaps others that I haven't thought of yet).

Yep, I was wrong in just blaming carriers and TPAs.

I also should have been finger pointing at Maximus too.

So I admit I'm wrong, which means ...

... I'm still right about DWC - either fine carriers and TPAs (and collect) and enforce whatever contractual provisions there are against Maximus for its administrative failures; i.e. do the job so we can bring some credibility and reliability back to the system.

Perhaps it's time to reopen the bidding process to other IMR providers, or perhaps there should be more than a single provider so we can see what some competition does (Texas has about 40 IMR providers).

There are only three true stakeholders in workers' compensation: employers pay for the system, injured workers are to be provided the benefits of the system, and the government is to enforce the system.

For purposes of this vignette, the only missing element is the government.

Do the job.


  1. Thanks. and just for the record, here in WA State the Employer and the Employee both pay for the system, and we both get taken, when folks are not honest with us in our care at the bed side, to lie and deny to push a bias social moral agenda, or cost contain for an industry's who profiteering pirating has gotten way out of control. Nationalizing Workers Comp, or some real strict federal over site is the only thing that is going to clean up this mess, and get the injured, back their grand bargain in full. Some folks really do feel that if you hit your thumb with a hammer at work, that the bargain should not cover that injury or any ill effect that may stem from that injury, if should happen to get infected and turn into amputation. But many folks just feel in their guts that our bargain should not be covering these minor work related injuries. Folks should watch what there doing. Until we teach and train folks, that our grand bargain, cover ALL work related injuries, even the little ones, are covered under the bargain. Folks should not be able to intently and knowingly violate our work comp admin laws at the bed side, knowing it will take their victims decades to get justice for the harm done if they ever do. All this to folks they have a duty to do no harm to in the first place. Until we educate all as to what the bargain is and what it does cover, many folks from the professional real are just going on gut instincts and personal bias judgement in our claims, and the objective medical facts tossed to the garbage, just like the used up injured aging injured workers.

    KEEP EDUCATING us all. And, it's OK to make a mistake, as long as you admit to it and make up for it, as you do so immediately, not decades down the road.

    Your all RIGHT, Mr. DePaolo, Rock ON!

  2. You've stirred up a hornets nest Mr. D. The poor little darlings have got their knickers in quite a bunch. It's a beautiful sight to behold for sure.