Auto accident injuries: Auto insurance or workers comp?

Transcription

1 NEWS FOR SUMMIT S PROVIDER COMMUNITY FALL 2013 Auto accident injuries: Auto insurance or workers comp? Auto accident injuries can create some complicated billing situations for health-care providers, especially when workers comp and auto insurance companies are both involved. Auto accident claims are often first directed to a patient s auto insurance carrier, even when the injury is work-related and rightfully covered under the employer s workers comp policy. This can be especially frustrating for patients because auto insurance medical payment coverage usually has a limit of liability. Workers comp, on the other hand, not only pays lost wages but also covers medical costs associated with the work injury (provided that the injury is proven to be compensable under the applicable state workers compensation law). If the workers comp company is not contacted to authorize further medical care when auto medical liability limits are surpassed, medical care can suffer from delays, and the billing can become more complicated. While the patient s treatment usually isn t impacted during emergency situations, these billing issues can make it difficult to schedule follow-up visits or specialist appointments. What you can do Many doctors rightfully question patients on the mechanics of the injury, but don t get the context. This is easy to fix. Simply ask your patient whether his auto accident injury was work-related and, if so, whether it has been reported to his employer or employer s workers comp carrier. This basic information can usually help clear up the question of compensability and help avoid billing hassles before they start. Distracted driving an alarming trend The risks of texting and driving are clear, but the problem persists. A study based on data gathered from more than 6,000 respondents (ages 16 and older) was released earlier this year by the U.S. Department of Transportation s National Highway Traffic Safety Administration. 1 The study showed that while most drivers support bans on hand-held cell phone use (74 percent) and texting while driving (94 percent), Americans continue to use electronic devices while driving at a disturbing rate. In fact, the study found that at any given daylight moment across America, approximately 660,000 drivers are using cell phones or manipulating electronic devices while driving. Many states have now enacted full or partial bans on distracted driving behaviors, such as texting or ing. 2 If you have patients who are injured while texting and driving on the job, they will likely be covered under workers compensation, provided the accident is proven to be compensable. 3 Provider profile...3 Survey drawing winner...4 Working with workers comp.. 5

2 Evidence-Based medicine Evidence-based medicine drives Texas success Workers comp reforms have been spreading across the country for the past decade. Texas experienced a major overhaul in May 2007.* One change was the state s adoption of the Official Disability Guidelines (ODG) for treatment of workers comp patients. Since then, Texas has seen some dramatic changes, such as lower costs for employers and improvements for injured workers. By January 2008, just a few months after reforms went into effect, the Texas Department of Workers Compensation reported a 44 percent decline in disputes and a 26 percent reduction in the average medical cost per claim. 5 By 2010, employer costs had dropped by 39 percent, making Texas the lowest cost state in the U.S. 5 In Texas, where workers compensation is voluntary for employers, coverage increased from 79 percent of workers in 2009 to 83 percent in Following the 2011 adoption of the ODG formulary, Texas saw a 75 percent reduction in new prescriptions for N drugs (opioids and other drugs not recommended by medical evidence). 7 In October 2012, the Insurance Council of Texas issued a report crediting the reforms with a 49 percent decrease in workers comp premiums paid by employers. 8 These changes are exciting for anyone participating in the workers comp system in Texas. Our goal is to improve the experience and care of injured workers, while simultaneously reducing costs for employers. Note: Texas is one of two states that allows employers to elect to carry workers comp coverage. See the next column for more information. * (28 TEX. ADMIN. CODE (2013) Opting Out: Texas and Oklahoma In May, Oklahoma made a major legislative change, allowing employers to opt out of the traditional state-mandated workers compensation system, much like their southern neighbor, Texas. In anticipation of the Oklahoma legislation, new research reviewed the opt-out program in Texas, and it offers some insight into what interested parties in Oklahoma may expect from employers. Researchers found that employers looking to drop their coverage might do so for a variety of reasons. In Texas, some of the top reasons employers cite for choosing to opt out of the state system have to do with medical care, e.g., they want more control over provider selection, stricter enforcement of evidence-based medicine practices and heavier regulation of opioid use. 9 What will happen next? Of course, we believe many of these issues are best controlled through the use of evidence-based guidelines and corresponding pharmaceutical formularies. And since implementing ODG, Texas has seen modest coverage gains, as noted in the previous article. It remains to be seen how many employers in Oklahoma will choose to opt out of the workers comp system, especially since the state also follows ODG. Another question is whether other states follow suit and allow such broad opt-out provisions in their own workers comp laws. Rest assured, Summit will be there to keep an eye on the issue. Reminder: Summit manages a carrier that writes business in Texas, but not Oklahoma. Want to learn more about ODG? Visit our website and click on Provider Resources and then Official Disability Guidelines (ODG). You ll find information about the product, as well as how to get a free trial and discounted subscription. The Official Disability Guidelines are a product of the Work Loss Data Institute. 2

3 Provider PROFILE Dr. Jerrold Young and the Hernia Institute of Florida Did you know that hernia injuries accounted for nearly 900 workers compensation claims in 2012 in Florida alone? 10 Many of those patients entrusted their surgical care to the team at the Hernia Institute of Florida in Miami. Dr. Jerrold Young, director of surgery, Dr. Jerrold Young gave us an insider s view of the how the Institute s team is revolutionizing the way physicians approach the surgical repair process. Traditional hernia treatment Most of you are familiar with the basics of hernia injury and treatment. There are many kinds of hernias, but one of the most common types is a tear in the muscle that separates the abdominal contents from the outside, most commonly in the inguinal area. Such hernias occur more often in men than in women and can be caused by unusual exertion of the muscle, coughing attacks or even significant changes in weight. Hernias are also more common among smokers, due to a higher occurrence of coughing and weakness in tissue collagen. Hernias do not heal on their own and are usually repaired to reduce pain and to eliminate the risk of strangulation (the entrapment of organs or other tissue in the opening). Surgery simply closes the opening, usually using a small piece of mesh. Treatment developments at the Hernia Institute At the Hernia Institute, doctors use a specialized mesh device, the Prolene Hernia System.* This mesh patch covers both sides of the opening, allowing for a tensionfree repair. By using the Prolene System, a surgeon can reduce patient discomfort, improve the recovery rate and greatly reduce surgical failures. Without a standard mesh, hernia repairs can fail and require a second surgery in about 15 to 20 percent of cases. After completing more than 11,500 repairs using the Prolene System, surgeons at the Institute have seen a much lower recurrence rate than that of even standard mesh only 0.25 percent! In addition, the typical recovery time is much shorter, with many patients reporting that they are pain-free after two to three days and back to work within a week or two. Compare that to a typical six-week recovery, and the difference is clear. Surgery...with service Given the dramatically reduced failure rate and shorter recovery time associated with the Prolene System, the Institute attracts patients from all over the country. More than half of the Institute s patients come from outside the Miami-Dade County area, and many come from outside of Florida altogether. To accommodate patients from out of town, the Hernia Institute offers a full concierge service program, which includes assistance with flight and hotel arrangements, ground transportation and even restaurant reservations. The concierge staff work to ensure a positive experience for each patient. A workers comp focus Many of the patients who travel to the Institute for treatment have work-related injuries. In fact, at last count the Institute has repaired more than 12,000 workrelated hernias since opening its doors in The doctors and staff give injured employees specialized care and understand that the goal of surgery is not only healing, but a return to their jobs and lives. They, like us, strive for winning solutions all around for injured workers and their employers. Here at Summit, we are proud to partner with many excellent medical facilities. A special thank you to Dr. Young and the Hernia Institute for an inside look into the world of hernia repair and the exciting possibilities for patient treatment and recovery. For more information on the Hernia Institute of Florida, visit their website at or give them a call at * The Prolene Hernia System was developed at the Hernia Institute and is now manufactured and marketed worldwide by Ethicon, a subsidiary of Johnson & Johnson. 3

4 For Your INFORmATION About Dr. Young and the Hernia Institute Dr. Jerrold Young attended McGill University and received his medical degree in He completed his surgical training at the University of Miami in 1976 and is a voluntary clinical associate professor in the department of surgery. He is also a diplomate of the American Board of Surgery and a Fellow of the American College of Surgeons (F.A.C.S.). He was governor of the American Hernia Society from 2006 to Dr. Young has served as the chief of general surgery for both the Baptist and South Miami Hospitals. Today, he serves as the director of surgery at the Hernia Institute. The Hernia Institute of Florida was founded in 1986 by Dr. Arthur Gilbert for the study and advancement of hernia surgery a goal that continues today. Surgeons at the Institute perform only hernia repairs more than a thousand surgeries each year. It is one of only a few facilities in the world that specializes in this condition and has become well-known internationally for the quality of its work. More than 35,000 hernias have been repaired at the Institute since it was founded. Neurological practice wins free lunch Congratulations to Dr. John Amann of Neurology and Neurosurgery Associates! Dr. Amann was one of many who responded to The Heritage News survey this past summer, and he won the prize drawing for survey participants. He and his entire office will receive lunch on us. Dr. Amann specializes in neurological surgery and is a member of several state and national professional associations dedicated to his specialty. He has been in practice since Neurology and Neurosurgery Associates, P.A., has been providing specialized neurological services in Winter Haven, Florida, since Today, the team includes seven physicians, three certified physician assistants and a full neuroancillary clinical staff, including an on-site physical therapist. Their broad range of services includes various spinal surgical procedures, carpal tunnel release, neurological sports medicine, sleep studies, interventional pain management and pediatric neurological care. For more information on Neurology and Neurosurgery Associates, visit their website, or call Above and beyond We recently received a note from one of our insured businesses expressing how thankful they were to Dr. Young for his extra care of one of their injured employees. Dr. Young not only stayed well beyond his own scheduled work hours to treat the patient, but also drove the injured worker to the hospital in his personal vehicle instead of arranging transport via ambulance. After surgery, he followed up to ensure the patient had transportation to future appointments, and he spoke personally to the pharmacist to have the appropriate medications approved and delivered. Thank you, Dr. Young, for going above and beyond, and for taking a personal interest in the recovery of your patients! Thank you! A special thanks to everyone who participated in The Heritage News survey. We are always looking for ways to improve our communications with you, and your input is vital to reaching that goal. We will be using your responses to help shape our future publications. If at any time you would like to provide feedback about our newsletter content, please send an to heritagenews@summitholdings.com. 4

5 Working with WORkERS COmP ERA matters to employers not just to baseball fans Nope, we re not talking about earned run average. This ERA stands for Experience Rating Adjustment, and it can make a big difference to business owners. If you ve treated injured workers, you know there are two types of workers comp claims: medical-only and lost-time. Medical-only claims are just as the name implies costs associated with these claims are strictly medical. Lost time, or indemnity, claims are those in which the injured worker is entitled to lost wage payments. Wage payments kick in once the patient is out of work for longer than the state s mandated waiting period (see chart). State Waiting Periods for Lost-Time Wages 4 Number of days Alabama 3 Arkansas 7 Florida 7 Georgia 7 Kentucky 7 Louisiana 7 Mississippi 5 So what does this mean for your patients? Their employers are likely to want them back on the job before the wage payment waiting period is up! If the patient can be returned to work at full or modified duty, employers will certainly appreciate being promptly notified so that they have the opportunity to return About 78 percent their employee of the claims we see here to work. When at Summit are medical-only, medically possible, but these account for only returning patients 4 to 5 percent of claims to work before the expenses. These figures waiting period ends have remained relatively can save employers consistent year thousands of dollars after year. and, in turn, can help you establish positive, long-term relationships with businesses in your area. Of course, keeping a patient out of work or returning the patient to work with restrictions is entirely at your discretion. At Summit, we trust you to keep the best interest of the patient in mind and to work toward recovery first and foremost. Note: As of this printing, Texas is the only state in which Summit operates that has not approved the Experience Rating Adjustment. North Carolina 7 South Carolina 7 Tennessee 7 Texas 7 How does ERA fit into this? Many employers premium costs are partially determined by the mod (experience modification factor). If a claim is medical-only, just 30 percent of that claim s dollar amount is used in the mod calculation. But, if a claim has even a small indemnity payment, the full amount of the claim (medical and indemnity costs) are used in the mod calculation. That means a seemingly small indemnity payment could end up costing the employer more in premium. Need information and resources for getting your patient back on the job after a workplace injury? Visit our website and click on Provider Resources and then Back2Work to learn more about Summit s return-to-work program. To read articles about the benefits of return to work, click on The Heritage News link to access our newsletter archive. 5

6 References 1. NHTSA Survey Finds 660,000 Drivers Using Cell Phones or Manipulating Electronic Devices While Driving At Any Given Daylight Moment, National Highway Traffic Safety Administration press release, April Available at 2. Just three states left with no ban on texting while driving, e-wisdom news service, September 25, Available at insurance/auto-insurance/just-three-states-left-with-no-ban-on-texting-whiledriving /. 3. Texting on the Job + Injury = Workers Compensation Claim?, Workers Compensation Institute, August 26, Available at com/news/article/texting-on-the-job-can-injury-workers-compensation-claim. 4. ALA. CODE (2013); ARK. CODE ANN (West 2013); FLA. STAT. ANN (1) (West 2013); GA. CODE ANN (West 2013); KY. REV. STAT. ANN (West 2013); LA. REV. STAT. ANN. 23:1224 (2012); MISS. CODE ANN (West 2013); N.C. GEN. STAT. ANN (West 2013); S.C. CODE ANN (2012); TENN. STAT. ANN (West 2013); and TEX. [LAB.] CODE ANN (Vernon 2013). 5. Jurisdictional Adoptions of Treatment Guidelines in North America, Work Loss Data Institute, (August 12, 2013). 6. Workers Compensation, Benefits, Coverage and Cost National Academy of Social Insurance, August Available at sites/default/files/research/nasi_workers_comp_2010.pdf#page= Fewer Texas Workers Compensation Claims Include Opioids and Not- Recommended Prescriptions, Texas Department of Insurance press release, July Available at Who is Summit? With more than 35 years of experience, Summit is a leading provider of workers compensation insurance products and services to employers throughout the Southeast. Summit includes Summit Consulting LLC and its subsidiary, Heritage Summit HealthCare LLC, along with its affiliated insurers, Bridgefield Casualty Insurance Company and Bridgefield Employers Insurance Company. Summit is also the managing general agent of BusinessFirst Insurance Company, Retailers Casualty Insurance Company, and RetailFirst Insurance Company. For a full listing of the workers compensation payor customers who lease and have access to the Heritage Summit HealthCare LLC preferred provider network, visit the Provider Resources section of our website and click on State-specific payors. How to Contact Us Heritage Summit HealthCare PO Box 3623 Lakeland, FL Texas Employers See 49% Drop in Work Comp Premiums, Insurance Council of Texas press release, October 17, Available at 9. Workers Compensation Opt-Out: Can Privatization Work? The Texas Experiment and the Oklahoma Proposal, November The New Street Group. Available at pdf. 10. Workers Compensation Claims Database, Florida Department of Financial Services, (August 24, 2013). Holiday Hours Summit Claims Center PO Box 2928 Lakeland, FL hour injury reporting If you know of a provider who may be interested in joining our network, please give us a call or send an to provider.leads@ summitholdings.com. All Summit offices will be closed this holiday season in observance of the following holidays: Thanksgiving Thursday, November 28, 2013 Friday, November 29, 2013 If you have any questions or comments about the content of this newsletter, please send an to heritagenews@summitholdings.com. Christmas Day Wednesday, December 25, 2013 New Year s Day Wednesday, January 1, 2014 Even on holidays, injured workers or their employers can report injuries 24 hours a day, 7 days a week on our website or by calling our injury reporting line at /13 (13-074) We wish you and your staff a happy, healthy holiday season and new year! 6 Summit Consulting LLC has used its best efforts to select information for this publication from reliable sources, but cannot warrant that it is complete or accurate. Summit Consulting LLC does not assume and hereby disclaims any liability to any person for loss or damages caused by error or omission. Please check with your attorney for details about the laws as they may affect your specific business situation Summit Consulting LLC