Federally mandated State administered.
CASE
No one expects to get hurt, and yet we do, get hurt. The accidents that are reported are staggering in the type, nature and cost. Take the true case of a son and father painting the ceiling of a warehouse 20 feet in the air. They were both in buckets attached to one another.
The father had his safety harness on, the son had forgotten to attach his. The father went to pull the son’s bucket near him and it capsized. The son fell 20 ft. to the ground and broke his back.
As the law indicates: “state administered” means the individual states must determine what type of rules they require for their workers compensation law. Each state has the right to choose and in some states they also give the right to “opt out” for an employer or a city. This will leave the non-compliant entity exposed to a potential lawsuit, as explained below. Not all programs are beneficial to the worker. Workers Compensation programs across the nation have become a Maze to navigate for patients and physicians alike.
COST
Workers Compensation is a multibillion dollar business and has become a “Maze” to many physicians and patients alike. Initially there were simply premium based insurance companies that handled claims, payment and settlements. The “right to know” law was passed in 1985 and OSHA implemented regulations over employers to help keep workers safer. The financial costs of workers compensation increased substantially. Companies were created to control the costs.
TPA third party administrators, Adjusting companies, State funds, Second injury funds, Rehabilitation companies, work comp physician networks required severely discounted reimbursement, Case management, Self-insured and others.
Workers’ compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee’s right to sue his or her employer for the tort of negligence. The trade-off between assured, limited coverage and lack of recourse outside the worker compensation system is
known as “the compensation bargain”. One of the problems that the compensation bargain solved is the problem of employers becoming insolvent as a result of high damage awards. The system of collective liability was created to prevent that, and thus to ensure security of compensation to the workers….Wikipedia AMA Guides Each State determines which method they want to use for settling a case. Most states now use one of the AMA Guides as a guideline to create a fair objective method for reporting the final impairment rating. Some states have created their own guidelines but defer to the AMA Guides books on many occasions. The Federal Government uses both the 5th and 6th edition of the AMA guides. Social Security Disability requires and Impairment Rating as well. AMA vs Garcia Texas lawsuit The American Medical Association (AMA) sued Texas in a landmark case which was AMA vs
Garcia (State of Texas). At issue was the way Texas Work Comp Commission (TWCC) was using the AMA Guides 4th edition to determine the schedule of benefit. That meant they were using an impairment rating to decide how much money a person could get in a settlement. Texas had implemented using the AMA Guides 4th edition (which it still in use today) to calculate an Impairment Rating which then determined how much money the patient would get. This is called a “schedule of benefits”. Example: 10% IR is equivalent to $5,000. Texas won and created a new national standard on calculating monetary benefits for injured persons. This method is now used for any injured person throughout the country regardless is how they got hurt. It was a valid way to standardize the medical report process. An accurate Impairment Rating has become integral to the system of monetary compensation. This is why physicians it is critical that doctors get certified by AAEME (CIRS) and must be involved in producing the most credible and defensible Impairment rating report. Using WP5 software makes this happen. MAZE Physicians and Nurse Advocates are the buffer between the patient and the Maze. It is not an easy job because the physician requests are constantly being denied for access to tests and treatments which could be critical to help their patients get better. Sadly, even the adjusters interfere in patient care, with no medical experience at all. CASE Case in point, an adjuster arbitrarily cancelled a patient’s critical medication because she read on google that it was for high cholesterol. This medication was critical because of a catastrophic
car accident. He was a police officer on duty, T-boned by a 14 seater van while his car was at a red light. Due to the accident, he lost a large section of his intestines. He also had 8 fractures, ruptured bowel and bladder. He was under the care of the Chief of Gastroenterology at Mayo Clinic. This medication was being used to stop his throat from spasm due to his intestinal
injuries, thereby affecting his breathing. Adjuster was notified and chastised. LESSON Adjusters should not be allowed to make medical decisions and yet they are making them all the time. This is particularly true with some TPA companies who promise to save their companies
money. Physicians, warn your patients. File a complaint with the state and the employer. REFERENCE: The Analysis of Workers’ Compensation Laws by the US Chamber of Commerce is a resource book worth getting. This resource addresses all the laws, benefits and costs of the programs nationwide and throughout Canada. Check with your state to see what version of the AMA Guides is used or the version created by the state. If you cannot find what you need send over an email, and we will get you the information.
Workers’ compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee’s right to sue his or her employer for the tort of negligence. The trade-off between assured, limited coverage and lack of recourse outside the worker compensation system is
known as “the compensation bargain”. One of the problems that the compensation bargain solved is the problem of employers becoming insolvent as a result of high damage awards. The system of collective liability was created to prevent that, and thus to ensure security of compensation to the workers….Wikipedia AMA Guides Each State determines which method they want to use for settling a case. Most states now use one of the AMA Guides as a guideline to create a fair objective method for reporting the final impairment rating. Some states have created their own guidelines but defer to the AMA Guides books on many occasions. The Federal Government uses both the 5th and 6th edition of the AMA guides. Social Security Disability requires and Impairment Rating as well. AMA vs Garcia Texas lawsuit The American Medical Association (AMA) sued Texas in a landmark case which was AMA vs
Garcia (State of Texas). At issue was the way Texas Work Comp Commission (TWCC) was using the AMA Guides 4th edition to determine the schedule of benefit. That meant they were using an impairment rating to decide how much money a person could get in a settlement. Texas had implemented using the AMA Guides 4th edition (which it still in use today) to calculate an Impairment Rating which then determined how much money the patient would get. This is called a “schedule of benefits”. Example: 10% IR is equivalent to $5,000. Texas won and created a new national standard on calculating monetary benefits for injured persons. This method is now used for any injured person throughout the country regardless is how they got hurt. It was a valid way to standardize the medical report process. An accurate Impairment Rating has become integral to the system of monetary compensation. This is why physicians it is critical that doctors get certified by AAEME (CIRS) and must be involved in producing the most credible and defensible Impairment rating report. Using WP5 software makes this happen. MAZE Physicians and Nurse Advocates are the buffer between the patient and the Maze. It is not an easy job because the physician requests are constantly being denied for access to tests and treatments which could be critical to help their patients get better. Sadly, even the adjusters interfere in patient care, with no medical experience at all. CASE Case in point, an adjuster arbitrarily cancelled a patient’s critical medication because she read on google that it was for high cholesterol. This medication was critical because of a catastrophic
car accident. He was a police officer on duty, T-boned by a 14 seater van while his car was at a red light. Due to the accident, he lost a large section of his intestines. He also had 8 fractures, ruptured bowel and bladder. He was under the care of the Chief of Gastroenterology at Mayo Clinic. This medication was being used to stop his throat from spasm due to his intestinal
injuries, thereby affecting his breathing. Adjuster was notified and chastised. LESSON Adjusters should not be allowed to make medical decisions and yet they are making them all the time. This is particularly true with some TPA companies who promise to save their companies
money. Physicians, warn your patients. File a complaint with the state and the employer. REFERENCE: The Analysis of Workers’ Compensation Laws by the US Chamber of Commerce is a resource book worth getting. This resource addresses all the laws, benefits and costs of the programs nationwide and throughout Canada. Check with your state to see what version of the AMA Guides is used or the version created by the state. If you cannot find what you need send over an email, and we will get you the information.