Workers compensation cases touch many lives and many industries. Insurance employees, medical professionals, government officials, employees and employers all influence each other in different ways. And of course, a main motivator for everything in life is money. When people lose focus of this fact, it’s can lead them to be surprised about new developments. We’ll take you through how fee changes might affect you so you’re at least prepared should you start seeing any type of fishy behavior.
The Workers Compensation Research Institution held a conference where two doctors talked about their experience with fee changes. In the majority of states, they found that group health rates are lower than those of workers compensation. For the exact same services, the payer of workers comp is shelling out more than they would if the injured had gone through a group health service. Physicians across the board were found to have raised their prices if they weren’t charging as much as the fee schedule standard. It should be noted that most of these fees are some variation of Medicare fees (typically about 30 percent higher), but not every state operates this way. For example, Illinois works on billed charges, so much higher costs for the state than for group or Medicare.
In states where the fees are lower, there’s evidence to suggest that providers are simply classifying more injuries as work related so they can fall under the workers compensation price categories. This essentially helps balance out their net gain from offering care to workers. This means there’s a reason for them to lie regardless of exactly how the fee structures are made – they’ll simply be different reasons for each one. Because the decision rests with the doctors with little interference from outside sources, they can basically claim whatever they want.
As an employer, you should be aware of how your state structures the fees. Louisiana and California haven’t had their fees restructured for a while, and thus are quite low. Look to who has the incentive to lie. Obviously your employee has an incentive to lie that their back was injured at work rather than moving a sofa to the other side of their house, but the doctor may have motivation to side with the sofa-moving employee too. The study concluded that if reimbursement rates go up by 20 percent, then the doctor is 6 percent more likely to call your employee’s soft-tissue back injury a work-related injury. While that’s not certainly not a reason to panic that you’ll be inundated with fake claims, it is a reason to stay alert to how fee schedules are currently operating where you are so you can question and clarify if need be.
