Workers Compensation News
A New York trial court judge denied an American International Group Inc. unit’s request to compel a workers compensation policyholder into arbitration.
MONTGOMERY, Ala.—A logger who was bitten by a snake while working can’t collect workers compensation benefits because the accident did not arise during the course of his employment, according to an Alabama appellate court.
SAN FRANCISCO—California workers compensation indemnity claims frequency remains elevated after experiencing its first increase in more than a decade during 2010, according to the Workers’ Compensation Insurance Rating Bureau of California.
COLUMBUS, Ohio—An AT&T Technologies Inc. employee is eligible for workers compensation benefits because her retirement did not amount to an “abandonment of employment,” an Ohio appellate court ruled.
NEW YORK—The National Football League has created a wellness initiative that it says will provide mental health support and other assistance for current and former NFL players—thousands of whom are suing the league over concussion-related…
Workers compensation insurance prices are increasing, substantially in some cases, and policy offerings are diminishing as insurers seek to address unprofitable combined ratios amid rising indemnity and medical costs.
Multiline commercial insurers may be spreading some workers compensation cost increases onto employers’ general liability rates to protect valued accounts from the competition.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation News
The average duration of workers compensation temporary total disability claims benefits increased during the first half of 2011 in correlation with the struggling economy, according to a study by NCCI Holdings Inc.
CHICAGO—Workers compensation is the exclusive remedy for the widow of an auto dealership employee killed on the job while working as a “borrowed employee” at an affiliated business, according to an Illinois appellate court.
LOS ANGELES—A California appellate court has ruled against Liberty Mutual Group Inc., striking down the insurer’s argument that its adjusters are exempt from state laws that require they be paid overtime.
OAKLAND, Calif.—Workers compensation claim frequency fell 2.1% last year for private self-insured employers in California, according to the California Workers’ Compensation Institute.
As baby boomers enter their 50s and 60s, society and the workplace are bracing for dramatic changes in demographics. As workforces age, employers must address many issues including making workplaces safer for older workers.
CHARLESTON, W.Va.—NCCI Holdings Inc. is seeking to reduce West Virginia workers compensation loss cost rates by 9.1% beginning Nov. 1, West Virginia Gov. Earl Ray Tomblin announced Wednesday.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
Drug abusers and criminal drug pushers rely on fraudulent insurance claims, including workers compensation claims, to obtain illicit prescription narcotic pain killers.
State regulations that cap the prices doctors can charge when dispensing pharmaceutical drugs work effectively to reduce workers compensation costs, yet they do not limit patient access to pharmaceuticals, a study released Thursday reports.
A waiter at TGI Friday’s in Virginia bit off more than he could chew when he filed for workers compensation benefits after choking on a quesadilla.
ALBANY, N.Y.—New York Gov. Andrew Cuomo announced Tuesday that New York employers will see a 1.2% rate decrease for workers compensation policies incepting on or after Oct. 1.
A workers compensation experience modification factor is a component of the formula used to adjust a manually rated premium for the difference between a particular organization’s “inherent risk and the average risk for all companies with payrolls…
Employers with poor loss histories will pay even more for their workers comp coverage starting next year as most states change the way premiums are calculated.
A Northern California woman seen trading her crutches for high-heeled shoes before running into a public park for a sexual romp has pleaded not guilty to workers compensation insurance fraud.
COLUMBIA, S.C.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
BOCA RATON, Fla.—Workers compensation lost-time claim frequency declined by 1% in 2011, according to a report from NCCI Holdings Inc.
CAMBRIDGE, Mass.—Lump-sum settlement of workers compensation claims encourage injured employees to return to work, the Workers Compensation Research Institute reported Wednesday.
The use of Schedule II opioid painkillers to treat injured California workers has dropped to its lowest level since 2007, according to a study that the California Workers’ Compensation Institute released Tuesday.
ST. LOUIS—Roger B. Wilson, the former CEO of Missouri Employers Mutual Insurance Co., was sentenced to two years probation Monday for misusing funds from the state workers compensation insurer.
WASHINGTON—The Food and Drug Administration has approved a risk management plan to help combat the misuse and abuse of long-acting opioid prescription pain medications.
AUSTIN, Texas—Communications between an employer and an attorney for the employer’s workers compensation insurer do not enjoy attorney-client privilege protection, the Supreme Court of Texas ruled in a bad-faith case.
SPRINGFIELD, Ill.—The Illinois Department of Insurance has placed Lumbermens Mutual Casualty Co. and an affiliated insurer, American Manufacturers Mutual Insurance Co., into rehabilitation, the state announced Tuesday.
BOSTON—Wal-Mart Stores Inc. and Target Corp.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Some Doctors Cash In by Being Their Own Pharmacist
The same goes for a popular muscle relaxant known as Soma, insurers say. From a pharmacy, the per-pill price is 60 cents. Sold by a doctor, it can cost more than five times that, or $3.33.
At a time of soaring health care bills, experts say that doctors, middlemen and drug distributors are adding hundreds of millions of dollars annually to the costs borne by taxpayers, insurance companies and employers through the practice of physician dispensing.
Most common among physicians who treat injured workers, it is a twist on a typical doctor’s visit. Instead of sending patients to drugstores to get prescriptions filled, doctors dispense the drugs in their offices to patients, with the bills going to insurers. Doctors can make tens of thousands of dollars a year operating their own in-office pharmacies. The practice has become so profitable that private equity firms are buying stakes in the businesses, and political lobbying over the issue is fierce.
Doctor dispensing can be convenient for patients. But rules in many states governing workers’ compensation insurance contain loopholes that allow doctors to sell the drugs at huge markups. Profits from the sales are shared by doctors, middlemen who help physicians start in-office pharmacies and drug distributors who repackage medications for office sale.
Alarmed by the costs, some states, including California and Oklahoma, have clamped down on the practice. But legislative and regulatory battles over it are playing out in other states like Florida, Hawaii and Maryland.
In Florida, a company called Automated HealthCare Solutions, a leader in physician dispensing, has defeated repeated efforts to change what doctors can charge. The company, which is partly owned by Abry Partners, a private equity firm, has given more than $3.3 million in political contributions either directly or through entities its principals control, public records show.
Insurers and business groups said they were amazed by the little-known company’s spending spree. To plead its case to Florida lawmakers, Automated HealthCare hired one of the state’s top lobbyists, Brian Ballard, who is also a major national fund-raiser for the Mitt Romney campaign.
“I consider the fees that these people are charging to be immoral,” said Alan Hays, a Republican state senator in Florida who introduced a bill to bar physicians from dispensing pills that was defeated. “They’re legal under the current law, but they’re immoral.”
Physician prescribing works like this: Middlemen like Automated HealthCare help doctors set up office pharmacies by providing them with billing software and connecting them with suppliers who repackage medications for office sale. Doctors sell the drugs but they do not collect payments from insurers. In the case of Automated HealthCare, the company pays the doctor 70 percent of what the doctor charges, then seeks to collect the full amount from insurers.
The number of doctors nationwide who dispense drugs in their office is not known and the practice is prevalent only in states where workers’ compensation rules allow for large markups.
Dr. Paul Zimmerman, a founder of Automated HealthCare, said that insurers and other opponents of doctor dispensing were distorting its costs by emphasizing the prices of a few drugs, rather than the typical price spread between physician- and pharmacy-dispensed drugs.
Both Dr. Zimmerman and physicians who sell drugs also said the workers’ compensation system was so bureaucratic and complex that an injured employee could wait days before getting a needed medication through a pharmacy.
“We did not institute this because of the money,” Dr. Marc Loev, a managing partner of the Spine Center, a chain of clinics in Maryland, testified last year at a public hearing in Baltimore. “We instituted it because we were having significant difficulty providing the care for workers’ compensation patients.”
The loophole that raises the price of physician-dispensed drugs often involves a benchmark called “average wholesale price.” The cost of a medication dispensed through a workers’ compensation plan is pegged in some states to that benchmark, which is supposed to represent a drug’s typical wholesale cost.
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2012/07/12/business/some-physicians-making-millions-selling-drugs.html?partner=rssnyt&emc=rss
For Injured Workers, a Costly Legal Swamp
People like Hopeton Watkis, 64, a laborer, who lost two teeth when he fell and hit a wheelbarrow.
Or Rajcoomar Jagan, 50, a construction worker, who injured a leg falling off a scaffold.
Or Vicki Marquez, 32, a retail sales associate, who hurt her elbow hauling clothes.
They come to the board seeking authorization for medical treatment and replacement wages — in short, a quick and fair resolution from a system set up to replace fractious court fights between employers and employees.
What they find instead is a subbasement of the legal world, a $5.5 billion-a-year state-run bureaucracy that, an examination by The New York Times found, struggles to treat workers with due speed, protect employers from fraud or mute tensions in the workplace.
These struggles are particularly evident each day in Queens, the state’s busiest hearing office, where The Times spent 18 months attending hearings, reviewing cases and interviewing participants, virtually none of whom defended the system as efficient.
At some hearings, as judges looked on, lawyers chatted on cellphones, cracked bawdy jokes or read newspapers during testimony. Expert witnesses seemed biased to the point of caricature. Claims dragged on, but hearings seldom exceeded a few blurred minutes, rarely proved conclusive and were conducted in baffling shorthand.
Mr. Watkis waited two years to get his front teeth fixed. Ms. Marquez had to postpone elbow surgery for a year until the board allowed it. Mr. Jagan exhausted three years trying to get compensated, only to be denied all benefits, a decision that stunned even some insurance company lawyers.
“Comparing Supreme Court, say, to this is like comparing a hospital to a MASH unit,” said Anthony Pizza, a lawyer for insurance companies. “A lot of it is meatball justice.”
Workers’ compensation systems across the country are troubled, and reform efforts are under way here. But New York, a pioneer of the concept and home to the nation’s second-largest system, has some signature claims to dysfunction and is widely recognized as the most adversarial.
Though its commissioners largely function as a legal tribunal, most are not lawyers but relatives or allies of politicians, appointed usually without regard to experience in the field.
Though many cases turn on medical evaluations, the board has not had its own medical director for nearly a decade. Decisions are often driven by the opinions of doctors certified by the state as so-called independent medical examiners. Yet claimant lawyers and treating doctors say these examiners often understate workers’ ailments to win business from the insurers who pay them.
Fines for infractions are usually small, and some insurers ignore paying them for years without consequence. A few months ago, New York City agreed to produce $1.1 million in penalties, some years overdue.
Workers are known to fabricate claims, while employers can be equally uninhibited about pressuring injured workers against filing for compensation, or punishing them if they do.
And everywhere the system tolerates delays that can make the injured wait months or years for money and care. Statewide, in about one in six cases, insurers dispute that injuries are real or were suffered on the job. Until recently, these cases had averaged nearly nine months to resolve. And many of them remain unresolved years later.
Even unchallenged cases plod on. A.I.G., the insurance company, said a review of its 2007 New York cases found that those involving missed work took on average 802 days to reach a final stage, 30 percent longer than in the rest of the country.
A recent task force study found that when insurers reject a medical procedure, say, an operation, it takes more than three or four months for the board to settle the dispute. The delay can mean that injuries heal slowly or improperly, and in 75 percent of those cases, the worker’s need for the procedure is upheld.
Zachary S. Weiss, the chairman of the compensation board since late 2007, said that given the scope of what needs to be done, change must be incremental.
“There are millions of things I would like to correct and I’d like to correct them all immediately, and I can’t,” Mr. Weiss said.
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2009/03/31/nyregion/31comp.html?partner=rssnyt&emc=rss
Exams of Injured Workers Fuel Mutual Mistrust
Dr. Hershel Samuels, an orthopedic surgeon, put his hand on the worker’s back. “Mild spasm bilaterally,” he said softly. He pressed his fingers gingerly against the side of the man’s neck. “The left cervical is tender,” he said, “even to light palpation.”
Skip to next paragraph
A World of Hurt
‘That’s the Game, Baby’
A New York Times examination of New York State’s workers’ compensation system uncovered a universe of delays, suspicion and questionable rulings.
Further Reading
Workers’ Compensation
A page of resources on the topic of workers’ compensation compiled by the reporters of this series.
Multimedia
One Exam, Two Verdicts on Pain
Dr. Edward Toriello feels that workers doctors are often biased. I think its human nature to help your
patient. I think a lot of doctors say: I dont need the aggravation. It doesnt hurt to keep him out of work.
The worker, a driver for a plumbing company, told the doctor he had fallen, banging up his back, shoulder and ribs. He was seeking expanded workers’ compensation benefits because he no longer felt he could do his job.
Dr. Samuels, an independent medical examiner in the state workers’ compensation system, seemed to agree. As he moved about a scuffed Brooklyn office last April, he called out test results indicative of an injured man. His words were captured on videotape.
Yet the report Dr. Samuels later submitted to the New York State Workers’ Compensation Board cleared the driver for work and told a far different story: no back spasms, no tender neck. In fact, no recent injury at all.
“If you did a truly pure report,” he said later in an interview, “you’d be out on your ears and the insurers wouldn’t pay for it. You have to give them what they want, or you’re in Florida. That’s the game, baby.”
Independent medical exams are among the most disputed components of New York’s troubled workers’ compensation system. Under that system, workers with bona fide injuries are entitled to medical care and replacement wages, usually paid for by their employer’s insurer.
The independent exams are designed to flush out workers who exaggerate injuries or get unnecessary care, and there is no question that some of that goes on. As a check on what a worker’s doctor determines, insurers are allowed to order an ostensibly neutral exam by a doctor they select and pay for. They do so regularly, with more than 100,000 exams conducted each year.
But a New York Times review of case files and medical records and interviews with participants indicate that the exam reports are routinely tilted to benefit insurers by minimizing or dismissing injuries.
“You go in and sit there for a few minutes and out comes a six-page detailed exam that he never did,” said Dr. Stephen M. Levin, co-director of the occupational and environmental medicine unit at Mount Sinai Medical Center, who has been picked as the interim medical director at the compensation board. “There are some noble things you can do in medicine without treating. This ain’t one of them.”
New York uses independent medical examiners far more extensively than many states do, and critics say the practice adds to the mistrust in the system. The examiners’ opinions can empower an insurer to slash benefits, withhold medical treatment or stall a case. Workers say that psychologically, there is something particularly damaging about being dishonestly evaluated by a medical professional.
“I was in so much pain and felt so hopeless for so long,” said Carol Houlder, a substance abuse counselor who waited a year for surgery on her injured ankle to be approved. “Doctors see you’re in pain and say you’re not. How do they call themselves doctors?”
Many independent examiners are older, semiretired physicians who no longer treat patients, and claimants and lawyers have asserted that the memories and judgments of some of the doctors have at times been impaired by their age and frailties. The examiners do not need special training, only to have a state license and to be authorized in a specialty.
“Basically if you haven’t murdered anyone and you have a medical license, you get certified,” said Dr. Alan Zimmerman, 75, a Queens orthopedic surgeon who does the exams. “It’s clearly a nice way to semiretire.”
Some examiners see dozens of injured workers a day. Often the appointments are booked by brokers who help insurance companies find doctors. Some brokers are not registered with the state, as required, but there has been little enforcement of the rules.
Insurers, examiners and brokers, however, defend the exams as necessary and largely untarnished by bias. Dr. Brian L. Grant, chairman of Medical Consultants Network, a company based in Seattle that arranges independent exams across the country, said, “We never get pressure from an insurer.”
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2009/04/01/nyregion/01comp.html?partner=rssnyt&emc=rss
Workers Compensation NEws
SACRAMENTO—A California state agency has approved a $6.17 billion alternative security program to guarantee the 2012 and 2013 workers compensation risk for participating self-insured California employers.
SALEM, Ore.
SACRAMENTO, Calif.
Employers renewing their workers compensation policies likely will pay more for the coverage as claims costs rise and insurers’ combined ratios deteriorate, experts say.
A 91-year-old Canadian pilot wants workers compensation benefits for an accident that happened nearly 60 years ago while flying a crop duster over Manitoba farmland.
SALEM, Ore.—An Oregon police officer who was hit by a car while walking to get some coffee is entitled to workers compensation benefits because the accident happened in the course of her employment, the Oregon Court of Appeals has ruled.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
Oklahoma’s high court has rejected a workers compensation insurer’s argument that it should enjoy the same sovereign immunity as its policyholder, a casino owned by the Osage Nation.
CHICAGO—Subsidiaries of Boston-based Liberty Mutual Group Inc. have asked a federal judge to reverse a $450 million settlement paid by American International Group Inc. for its alleged underreporting of workers compensation premiums.
Workers compensation underwriters’ growing combined ratios will boost insurer attempts to increase policy premiums and fuel calls for new system reforms.
SAN FRANCISCO—The combined ratio for California workers compensation insurers rose to 122% during 2011, up from 117% in 2010, the Workers’ Compensation Insurance Rating Bureau of California reported.
“Repetitive walking” has joined the list of occupational hazards that could earn you workers compensation benefits in Illinois, according to news reports.
CAMBRIDGE, Mass.—Legislative reforms and management of medical care decreased the cost of workers compensation health care in Texas, the Cambridge, Mass.-based Workers Compensation Research Institute said in an analysis.
AUSTIN, Texas—The Texas Supreme Court has ruled that workers cannot use common law claims to sue workers compensation insurers for bad faith handling of a worker’s case.
DENVER—More environmental health and safety professionals need to learn risk financing concepts to take advantage of opportunities that result from communicating with the C-suite and insurance underwriters.
A study that shows a more than fivefold increase in the duration of workers compensation claims when the claimants are obese will help employers and insurers better manage related costs, experts say.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
COLUMBUS, Ohio—A man who worked in his wife’s business while collecting workers compensation benefits did not commit fraud because he did not know that his actions were defined as work, the Ohio Supreme Court said Tuesday.
With obesity a growing problem, expect more employers to address related workers comp and overall healthcare costs with creative measures that allow normally sedentary employees to move while they work.
ROCHESTER, N.Y.
BOCA RATON, Fla.—The duration of workers compensation indemnity benefits paid to obese workers is at least five times greater than those paid to claimants who are not obese but filed comparable claims, according to a new analysis.
TALLAHASSEE, Fla.—A law that limits workers compensation benefits to five years when an injured employee is 70 or older when a workplace accident occurs is constitutional, a Florida appeals court has ruled.
- Employer responsible for injured worke
Workers Compensation News
A New York trial court judge denied an American International Group Inc. unit’s request to compel a workers compensation policyholder into arbitration.
MONTGOMERY, Ala.—A logger who was bitten by a snake while working can’t collect workers compensation benefits because the accident did not arise during the course of his employment, according to an Alabama appellate court.
SAN FRANCISCO—California workers compensation indemnity claims frequency remains elevated after experiencing its first increase in more than a decade during 2010, according to the Workers’ Compensation Insurance Rating Bureau of California.
COLUMBUS, Ohio—An AT&T Technologies Inc. employee is eligible for workers compensation benefits because her retirement did not amount to an “abandonment of employment,” an Ohio appellate court ruled.
NEW YORK—The National Football League has created a wellness initiative that it says will provide mental health support and other assistance for current and former NFL players—thousands of whom are suing the league over concussion-related…
Workers compensation insurance prices are increasing, substantially in some cases, and policy offerings are diminishing as insurers seek to address unprofitable combined ratios amid rising indemnity and medical costs.
Multiline commercial insurers may be spreading some workers compensation cost increases onto employers’ general liability rates to protect valued accounts from the competition.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation News
The average duration of workers compensation temporary total disability claims benefits increased during the first half of 2011 in correlation with the struggling economy, according to a study by NCCI Holdings Inc.
CHICAGO—Workers compensation is the exclusive remedy for the widow of an auto dealership employee killed on the job while working as a “borrowed employee” at an affiliated business, according to an Illinois appellate court.
LOS ANGELES—A California appellate court has ruled against Liberty Mutual Group Inc., striking down the insurer’s argument that its adjusters are exempt from state laws that require they be paid overtime.
OAKLAND, Calif.—Workers compensation claim frequency fell 2.1% last year for private self-insured employers in California, according to the California Workers’ Compensation Institute.
As baby boomers enter their 50s and 60s, society and the workplace are bracing for dramatic changes in demographics. As workforces age, employers must address many issues including making workplaces safer for older workers.
CHARLESTON, W.Va.—NCCI Holdings Inc. is seeking to reduce West Virginia workers compensation loss cost rates by 9.1% beginning Nov. 1, West Virginia Gov. Earl Ray Tomblin announced Wednesday.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
Drug abusers and criminal drug pushers rely on fraudulent insurance claims, including workers compensation claims, to obtain illicit prescription narcotic pain killers.
State regulations that cap the prices doctors can charge when dispensing pharmaceutical drugs work effectively to reduce workers compensation costs, yet they do not limit patient access to pharmaceuticals, a study released Thursday reports.
A waiter at TGI Friday’s in Virginia bit off more than he could chew when he filed for workers compensation benefits after choking on a quesadilla.
ALBANY, N.Y.—New York Gov. Andrew Cuomo announced Tuesday that New York employers will see a 1.2% rate decrease for workers compensation policies incepting on or after Oct. 1.
A workers compensation experience modification factor is a component of the formula used to adjust a manually rated premium for the difference between a particular organization’s “inherent risk and the average risk for all companies with payrolls…
Employers with poor loss histories will pay even more for their workers comp coverage starting next year as most states change the way premiums are calculated.
A Northern California woman seen trading her crutches for high-heeled shoes before running into a public park for a sexual romp has pleaded not guilty to workers compensation insurance fraud.
COLUMBIA, S.C.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
BOCA RATON, Fla.—Workers compensation lost-time claim frequency declined by 1% in 2011, according to a report from NCCI Holdings Inc.
CAMBRIDGE, Mass.—Lump-sum settlement of workers compensation claims encourage injured employees to return to work, the Workers Compensation Research Institute reported Wednesday.
The use of Schedule II opioid painkillers to treat injured California workers has dropped to its lowest level since 2007, according to a study that the California Workers’ Compensation Institute released Tuesday.
ST. LOUIS—Roger B. Wilson, the former CEO of Missouri Employers Mutual Insurance Co., was sentenced to two years probation Monday for misusing funds from the state workers compensation insurer.
WASHINGTON—The Food and Drug Administration has approved a risk management plan to help combat the misuse and abuse of long-acting opioid prescription pain medications.
AUSTIN, Texas—Communications between an employer and an attorney for the employer’s workers compensation insurer do not enjoy attorney-client privilege protection, the Supreme Court of Texas ruled in a bad-faith case.
SPRINGFIELD, Ill.—The Illinois Department of Insurance has placed Lumbermens Mutual Casualty Co. and an affiliated insurer, American Manufacturers Mutual Insurance Co., into rehabilitation, the state announced Tuesday.
BOSTON—Wal-Mart Stores Inc. and Target Corp.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Some Doctors Cash In by Being Their Own Pharmacist
The same goes for a popular muscle relaxant known as Soma, insurers say. From a pharmacy, the per-pill price is 60 cents. Sold by a doctor, it can cost more than five times that, or $3.33.
At a time of soaring health care bills, experts say that doctors, middlemen and drug distributors are adding hundreds of millions of dollars annually to the costs borne by taxpayers, insurance companies and employers through the practice of physician dispensing.
Most common among physicians who treat injured workers, it is a twist on a typical doctor’s visit. Instead of sending patients to drugstores to get prescriptions filled, doctors dispense the drugs in their offices to patients, with the bills going to insurers. Doctors can make tens of thousands of dollars a year operating their own in-office pharmacies. The practice has become so profitable that private equity firms are buying stakes in the businesses, and political lobbying over the issue is fierce.
Doctor dispensing can be convenient for patients. But rules in many states governing workers’ compensation insurance contain loopholes that allow doctors to sell the drugs at huge markups. Profits from the sales are shared by doctors, middlemen who help physicians start in-office pharmacies and drug distributors who repackage medications for office sale.
Alarmed by the costs, some states, including California and Oklahoma, have clamped down on the practice. But legislative and regulatory battles over it are playing out in other states like Florida, Hawaii and Maryland.
In Florida, a company called Automated HealthCare Solutions, a leader in physician dispensing, has defeated repeated efforts to change what doctors can charge. The company, which is partly owned by Abry Partners, a private equity firm, has given more than $3.3 million in political contributions either directly or through entities its principals control, public records show.
Insurers and business groups said they were amazed by the little-known company’s spending spree. To plead its case to Florida lawmakers, Automated HealthCare hired one of the state’s top lobbyists, Brian Ballard, who is also a major national fund-raiser for the Mitt Romney campaign.
“I consider the fees that these people are charging to be immoral,” said Alan Hays, a Republican state senator in Florida who introduced a bill to bar physicians from dispensing pills that was defeated. “They’re legal under the current law, but they’re immoral.”
Physician prescribing works like this: Middlemen like Automated HealthCare help doctors set up office pharmacies by providing them with billing software and connecting them with suppliers who repackage medications for office sale. Doctors sell the drugs but they do not collect payments from insurers. In the case of Automated HealthCare, the company pays the doctor 70 percent of what the doctor charges, then seeks to collect the full amount from insurers.
The number of doctors nationwide who dispense drugs in their office is not known and the practice is prevalent only in states where workers’ compensation rules allow for large markups.
Dr. Paul Zimmerman, a founder of Automated HealthCare, said that insurers and other opponents of doctor dispensing were distorting its costs by emphasizing the prices of a few drugs, rather than the typical price spread between physician- and pharmacy-dispensed drugs.
Both Dr. Zimmerman and physicians who sell drugs also said the workers’ compensation system was so bureaucratic and complex that an injured employee could wait days before getting a needed medication through a pharmacy.
“We did not institute this because of the money,” Dr. Marc Loev, a managing partner of the Spine Center, a chain of clinics in Maryland, testified last year at a public hearing in Baltimore. “We instituted it because we were having significant difficulty providing the care for workers’ compensation patients.”
The loophole that raises the price of physician-dispensed drugs often involves a benchmark called “average wholesale price.” The cost of a medication dispensed through a workers’ compensation plan is pegged in some states to that benchmark, which is supposed to represent a drug’s typical wholesale cost.
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2012/07/12/business/some-physicians-making-millions-selling-drugs.html?partner=rssnyt&emc=rss
For Injured Workers, a Costly Legal Swamp
People like Hopeton Watkis, 64, a laborer, who lost two teeth when he fell and hit a wheelbarrow.
Or Rajcoomar Jagan, 50, a construction worker, who injured a leg falling off a scaffold.
Or Vicki Marquez, 32, a retail sales associate, who hurt her elbow hauling clothes.
They come to the board seeking authorization for medical treatment and replacement wages — in short, a quick and fair resolution from a system set up to replace fractious court fights between employers and employees.
What they find instead is a subbasement of the legal world, a $5.5 billion-a-year state-run bureaucracy that, an examination by The New York Times found, struggles to treat workers with due speed, protect employers from fraud or mute tensions in the workplace.
These struggles are particularly evident each day in Queens, the state’s busiest hearing office, where The Times spent 18 months attending hearings, reviewing cases and interviewing participants, virtually none of whom defended the system as efficient.
At some hearings, as judges looked on, lawyers chatted on cellphones, cracked bawdy jokes or read newspapers during testimony. Expert witnesses seemed biased to the point of caricature. Claims dragged on, but hearings seldom exceeded a few blurred minutes, rarely proved conclusive and were conducted in baffling shorthand.
Mr. Watkis waited two years to get his front teeth fixed. Ms. Marquez had to postpone elbow surgery for a year until the board allowed it. Mr. Jagan exhausted three years trying to get compensated, only to be denied all benefits, a decision that stunned even some insurance company lawyers.
“Comparing Supreme Court, say, to this is like comparing a hospital to a MASH unit,” said Anthony Pizza, a lawyer for insurance companies. “A lot of it is meatball justice.”
Workers’ compensation systems across the country are troubled, and reform efforts are under way here. But New York, a pioneer of the concept and home to the nation’s second-largest system, has some signature claims to dysfunction and is widely recognized as the most adversarial.
Though its commissioners largely function as a legal tribunal, most are not lawyers but relatives or allies of politicians, appointed usually without regard to experience in the field.
Though many cases turn on medical evaluations, the board has not had its own medical director for nearly a decade. Decisions are often driven by the opinions of doctors certified by the state as so-called independent medical examiners. Yet claimant lawyers and treating doctors say these examiners often understate workers’ ailments to win business from the insurers who pay them.
Fines for infractions are usually small, and some insurers ignore paying them for years without consequence. A few months ago, New York City agreed to produce $1.1 million in penalties, some years overdue.
Workers are known to fabricate claims, while employers can be equally uninhibited about pressuring injured workers against filing for compensation, or punishing them if they do.
And everywhere the system tolerates delays that can make the injured wait months or years for money and care. Statewide, in about one in six cases, insurers dispute that injuries are real or were suffered on the job. Until recently, these cases had averaged nearly nine months to resolve. And many of them remain unresolved years later.
Even unchallenged cases plod on. A.I.G., the insurance company, said a review of its 2007 New York cases found that those involving missed work took on average 802 days to reach a final stage, 30 percent longer than in the rest of the country.
A recent task force study found that when insurers reject a medical procedure, say, an operation, it takes more than three or four months for the board to settle the dispute. The delay can mean that injuries heal slowly or improperly, and in 75 percent of those cases, the worker’s need for the procedure is upheld.
Zachary S. Weiss, the chairman of the compensation board since late 2007, said that given the scope of what needs to be done, change must be incremental.
“There are millions of things I would like to correct and I’d like to correct them all immediately, and I can’t,” Mr. Weiss said.
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2009/03/31/nyregion/31comp.html?partner=rssnyt&emc=rss
Exams of Injured Workers Fuel Mutual Mistrust
Dr. Hershel Samuels, an orthopedic surgeon, put his hand on the worker’s back. “Mild spasm bilaterally,” he said softly. He pressed his fingers gingerly against the side of the man’s neck. “The left cervical is tender,” he said, “even to light palpation.”
Skip to next paragraph
A World of Hurt
‘That’s the Game, Baby’
A New York Times examination of New York State’s workers’ compensation system uncovered a universe of delays, suspicion and questionable rulings.
Further Reading
Workers’ Compensation
A page of resources on the topic of workers’ compensation compiled by the reporters of this series.
Multimedia
One Exam, Two Verdicts on Pain
Dr. Edward Toriello feels that workers doctors are often biased. I think its human nature to help your
patient. I think a lot of doctors say: I dont need the aggravation. It doesnt hurt to keep him out of work.The worker, a driver for a plumbing company, told the doctor he had fallen, banging up his back, shoulder and ribs. He was seeking expanded workers’ compensation benefits because he no longer felt he could do his job.
Dr. Samuels, an independent medical examiner in the state workers’ compensation system, seemed to agree. As he moved about a scuffed Brooklyn office last April, he called out test results indicative of an injured man. His words were captured on videotape.
Yet the report Dr. Samuels later submitted to the New York State Workers’ Compensation Board cleared the driver for work and told a far different story: no back spasms, no tender neck. In fact, no recent injury at all.
“If you did a truly pure report,” he said later in an interview, “you’d be out on your ears and the insurers wouldn’t pay for it. You have to give them what they want, or you’re in Florida. That’s the game, baby.”
Independent medical exams are among the most disputed components of New York’s troubled workers’ compensation system. Under that system, workers with bona fide injuries are entitled to medical care and replacement wages, usually paid for by their employer’s insurer.
The independent exams are designed to flush out workers who exaggerate injuries or get unnecessary care, and there is no question that some of that goes on. As a check on what a worker’s doctor determines, insurers are allowed to order an ostensibly neutral exam by a doctor they select and pay for. They do so regularly, with more than 100,000 exams conducted each year.
But a New York Times review of case files and medical records and interviews with participants indicate that the exam reports are routinely tilted to benefit insurers by minimizing or dismissing injuries.
“You go in and sit there for a few minutes and out comes a six-page detailed exam that he never did,” said Dr. Stephen M. Levin, co-director of the occupational and environmental medicine unit at Mount Sinai Medical Center, who has been picked as the interim medical director at the compensation board. “There are some noble things you can do in medicine without treating. This ain’t one of them.”
New York uses independent medical examiners far more extensively than many states do, and critics say the practice adds to the mistrust in the system. The examiners’ opinions can empower an insurer to slash benefits, withhold medical treatment or stall a case. Workers say that psychologically, there is something particularly damaging about being dishonestly evaluated by a medical professional.
“I was in so much pain and felt so hopeless for so long,” said Carol Houlder, a substance abuse counselor who waited a year for surgery on her injured ankle to be approved. “Doctors see you’re in pain and say you’re not. How do they call themselves doctors?”
Many independent examiners are older, semiretired physicians who no longer treat patients, and claimants and lawyers have asserted that the memories and judgments of some of the doctors have at times been impaired by their age and frailties. The examiners do not need special training, only to have a state license and to be authorized in a specialty.
“Basically if you haven’t murdered anyone and you have a medical license, you get certified,” said Dr. Alan Zimmerman, 75, a Queens orthopedic surgeon who does the exams. “It’s clearly a nice way to semiretire.”
Some examiners see dozens of injured workers a day. Often the appointments are booked by brokers who help insurance companies find doctors. Some brokers are not registered with the state, as required, but there has been little enforcement of the rules.
Insurers, examiners and brokers, however, defend the exams as necessary and largely untarnished by bias. Dr. Brian L. Grant, chairman of Medical Consultants Network, a company based in Seattle that arranges independent exams across the country, said, “We never get pressure from an insurer.”
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Article source: http://www.nytimes.com/2009/04/01/nyregion/01comp.html?partner=rssnyt&emc=rss
Workers Compensation NEws
SACRAMENTO—A California state agency has approved a $6.17 billion alternative security program to guarantee the 2012 and 2013 workers compensation risk for participating self-insured California employers.
SALEM, Ore.
SACRAMENTO, Calif.
Employers renewing their workers compensation policies likely will pay more for the coverage as claims costs rise and insurers’ combined ratios deteriorate, experts say.
A 91-year-old Canadian pilot wants workers compensation benefits for an accident that happened nearly 60 years ago while flying a crop duster over Manitoba farmland.
SALEM, Ore.—An Oregon police officer who was hit by a car while walking to get some coffee is entitled to workers compensation benefits because the accident happened in the course of her employment, the Oregon Court of Appeals has ruled.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
Oklahoma’s high court has rejected a workers compensation insurer’s argument that it should enjoy the same sovereign immunity as its policyholder, a casino owned by the Osage Nation.
CHICAGO—Subsidiaries of Boston-based Liberty Mutual Group Inc. have asked a federal judge to reverse a $450 million settlement paid by American International Group Inc. for its alleged underreporting of workers compensation premiums.
Workers compensation underwriters’ growing combined ratios will boost insurer attempts to increase policy premiums and fuel calls for new system reforms.
SAN FRANCISCO—The combined ratio for California workers compensation insurers rose to 122% during 2011, up from 117% in 2010, the Workers’ Compensation Insurance Rating Bureau of California reported.
“Repetitive walking” has joined the list of occupational hazards that could earn you workers compensation benefits in Illinois, according to news reports.
CAMBRIDGE, Mass.—Legislative reforms and management of medical care decreased the cost of workers compensation health care in Texas, the Cambridge, Mass.-based Workers Compensation Research Institute said in an analysis.
AUSTIN, Texas—The Texas Supreme Court has ruled that workers cannot use common law claims to sue workers compensation insurers for bad faith handling of a worker’s case.
DENVER—More environmental health and safety professionals need to learn risk financing concepts to take advantage of opportunities that result from communicating with the C-suite and insurance underwriters.
A study that shows a more than fivefold increase in the duration of workers compensation claims when the claimants are obese will help employers and insurers better manage related costs, experts say.
Digest powered by RSS Digest
Rating: 0.0/10 (0 votes cast)
Rating: 0 (from 0 votes)
Workers Compensation NEws
COLUMBUS, Ohio—A man who worked in his wife’s business while collecting workers compensation benefits did not commit fraud because he did not know that his actions were defined as work, the Ohio Supreme Court said Tuesday.
With obesity a growing problem, expect more employers to address related workers comp and overall healthcare costs with creative measures that allow normally sedentary employees to move while they work.
ROCHESTER, N.Y.
BOCA RATON, Fla.—The duration of workers compensation indemnity benefits paid to obese workers is at least five times greater than those paid to claimants who are not obese but filed comparable claims, according to a new analysis.
TALLAHASSEE, Fla.—A law that limits workers compensation benefits to five years when an injured employee is 70 or older when a workplace accident occurs is constitutional, a Florida appeals court has ruled.
DES MOINES, Iowa—An Iowa hospital must pay for an injured worker’s unauthorized chiropractor visits because it failed to provide the man with timely medical care, the Iowa Court of Appeals said Wednesday.
Digest powered by RSS Digest
DES MOINES, Iowa—An Iowa hospital must pay for an injured worker’s unauthorized chiropractor visits because it failed to provide the man with timely medical care, the Iowa Court of Appeals said Wednesday.
Digest powered by RSS Digest
