If you want to understand the brick wall facing injured workers seeking medical treatment in some states just read the recent article published in the ABA Journal. The title says it all —
Insult to Injury: Texas Workers’ Comp System Denies, Delays Medical Help
The article begins by telling the story of a Deputy Sheriff who faced a nightmare of denials and delays in his medical care after being shot while in the line of duty. Those issues included the carrier even claiming the emergency helicopter ride to the hospital for life-saving care was not necessary.
This is not acceptable. The article paints a picture of Texas where the system may be at its worst. However, these problems are not unique to Texas. They occur in Alabama as well. In the last few years, they have progressively worsened.
The primary purpose of workers’ compensation laws is to rehabilitate injured workers so they may return to gainful employment if possible. More and more, we are losing our focus on this purpose. I hear it from my clients daily – “I want to work. I have to get medical treatment.” Yet, they are often frustrated by a system that seems to work against providing medical care.
Clearly, the workers compensation carriers are cutting their costs at the expense of those with serious injuries. Yet, I would not call this a cost “saving” measure. Instead, it is a cost “shifting” measure. The reality is, workers compensation carriers are shifting the costs from themselves to the rest of us. Medical costs for work-related injuries should be paid out of the large premiums collected by carriers. Instead, when legitimate claims are denied or delayed, others shoulder those costs. As taxpayers, we often pay those costs through programs such are Medicare or Medicaid. On another level, families sometimes become overburdened by the costs of getting basic care and the loss of income while out of work.
The article quotes a recently retired Texas official who spent his career handling workers compensation issues and best expressed the carrier misconduct that frustrates injured workers and the medical system so greatly. According to this official:
Sometimes they just create a controversy as to whether they owe on a claim.
What are some of the common actions taken by carriers to create a bad reason for denying care? What practices are used to wrongfully deny or delay medical treatment to injured workers? Here are a few:
- Claim A Pre-Existing Problem. I have written about this issue previously. Don’t simply accept such a denial if you were able to do your job before suffering a work-related injury. It is not necessary that you have been in perfect health before that injury.
- Bury The Doctor in Paperwork. Doctors should spend most of their time treating patients not completing forms. I have seen far too many cases where the doctor eventually became frustrated and simply gave up because of the level of paperwork required for a claim to get approved. If your doctor has talked to you about your injury and the need for medical care, then he has most likely put those opinions in your medical records. That should be sufficient.
- Use The “Utilization Review” Process. Alabama law has an administrative review process that was created to evaluate medical issues that are unclear for a variety of legitimate reasons. Yet, carriers often use the review process as a means to delay or deny legitimate care. How is this process abused? Sometimes, the carrier will use it to place extra paperwork burdens on the treating doctor. Sometimes, the carrier will pay another medical provider for a negative opinion about the requested medical care. This is called “peer review.” However, it is really just a negative report purchased from someone who never examined you, may not have seen all your records, and may not even be the right type of specialist for your injury. You don’t have to accept the delays or denials of this process. Instead, you can seek a remedy in court in Alabama.
- Employ A Bad Case Nurse To Work The System. Let me start by saying that there are plenty of good nurses that try to help injured workers navigate a difficult medical system. The bad ones gather information to use against you, try to manipulate the doctors, and work to slow the process. Good or bad, they all approach with a smile and promises of help. Since you cannot tell the difference, my advice is to act with caution. Be friendly but do not provide personal information. Don’t discuss your family, job history, finances, or other health issues and injuries. Keep your discussions to scheduling your next appointment and making sure the treatment requested by the doctor is getting approved quickly.
- Require Multiple Opinions. Alabama law does give the workers compensation carrier some rights to get a second medical opinion. However, some carriers abuse this limited right by requiring you to get multiple opinions until the carrier gets one it likes. Another way some carriers abuse this right is by using it as a means to switch your care from a doctor you may like to one more favorable to the carrier. The carrier cannot legitimately do that and you should not accept it.
Too often employees suffering significant injuries are left without proper medical care because of carrier misconduct. That is not acceptable. That is why it is so important to stay alert to these issues that benefit the bad carriers at the expense of everyone else.by Jeff Blackwell