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Medical Treatment Under Workers' Compensation
By Julius Young, Esq.

Applicants' attorney Julius Young publishes the WorkersCompZone lawblog.

Judges and attorneys know it as a frequent scenario. An injured worker, frustrated with the delays and treatment denials in the system, simply wishes to cash out their case. As part of a buyout they usually take a negotiated amount of money in exchange for releasing the insurer from liability for future medical treatment. Perhaps the worker has other coverage that can be relied upon to fund treatment. But maybe not.

Workers who have employer sponsored group health coverage or private coverage administered by companies such as Blue Cross or Blue Shield may find that their treatment is denied under the terms of the policy if the policy excludes payment for workers' comp related conditions.

What about workers who have no insurance or whose insurance will not cover workers' comp? Once they settle their cases, how do they fare? Some of those workers may be eligible for Medicare, so they are expected under Medicare's rules to “protect Medicare's interest” by using an allocated portion of their settlement (a Medicare Set Aside) to cover medical costs before Medicare will willingly kick in.

Others will use their group or individual medical insurance anyway, despite exclusionary language, hoping that their usage of treatment resources caused by a work injury is not flagged by the insurer. Some will seek treatment at the VA or public clinics or county hospitals. Some may receive “charity care”. If there is any research on how workers who settle cases access treatment resources, I'm not aware of such studies.

Perhaps the Affordable Care Act/Obamacare will affect all of this. But for now it's not clear how many injured workers end up having to pay for treatment “out of pocket” after cases are settled. But I'm sure there are some who do. I was thinking about those workers as I noted that the Centers for Medicare and Medicaid Services has now released a study of hospital pricing. The study documents hospital-specific charge data on the 100 most frequently billed discharges from 3,000 U.S. hospitals. The study documents that there is a huge range of billed charges from hospitals for the same procedure. Insurers may get discounts. But if you are an uninsured injured worker without insurance, you may be charged the “rack rate” just as you would be if you walked up to a hotel and booked a room without a discounted reservation. For example, a joint replacement may on average be billed at $83,538 at California Pacific Medical Center in San Francisco and $110,305 at St. Francis Memorial in San Francisco, just a couple of miles across the city. The same procedure at a local Kaiser was on average billed at less than half the cost.

Where injured workers have settled their cases and later found themselves without coverage, have they done comparison shopping?

Perhaps. I have personally represented several workers who settled their cases and used the funds to seek medical treatment in India or Thailand at a lower cost. Undoubtedly some immigrant workers from Mexico return there to get treatment. But for workers who need to treat in the USA, obtaining such data has been hard until now. For those workers who have settled their cases and are without other viable coverage, the CMS data may be helpful in choosing where to have elective treatments performed.

Here is a link to the CMS site where data can be obtained on charging practices of specific hospitals (the site has a search function to search for the hospital of your choice)

Here is another link to the CMS study

Here is a link to a New York Times analysis of the study

Stay tuned.

Julius Young, Esq.
Boxer & Gerson, LLP
300 Frank Ogawa Plaza Rotunda Building - Suite 500
Oakland, CA 94612
Toll Free: 888-326-0229

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