MEDICAL GUIDELINES IN WC CASES APPROVED BY TEXAS SP CT
"In this opinion, we conclude that the Legislature authorized TWCC to set upper limits on reimbursement amounts and establish a reasonable time limitation on requests for medical dispute resolution. TWCC acted consistently with the Legislature’s mandates - (1) the establishment of fair and reasonable guidelines designed to ensure quality medical care for injured workers, TEX. LAB. CODE § 413.011(b), (2) the achievement of effective medical cost control in the workers’ compensation system, id., and (3) the establishment of a program for resolution of disputes regarding health care treatments and services, id. § 413.013(1). "
Texas Workers' Compensation Commission v. Patient Advocates of Texas, et al, Decided May 28, 2004.
THE QUALITY OF WC HEALTH CARE
The American Society of Workers' compensation Professionals (AMCOMP) is concerned about poor quality of care.
Risk and Insurance
INJURED WORKERS’ ADVOCATES CALL FOR INSURERS TO CUT RATES BY 30%, RATE REGULATION
Advocates for injured workers today called for workers’ compensation insurers to reduce premiums by 30% to pass on to employers billions of dollars from two rounds of cuts to injured workers’ medical care and benefits. Insurance Commissioner John Garamendi today issued his pure premium advisory rate calling for a reduction of 21%. An industry-dominated research organization, the California Workers’ Compensation Insurance Rating Bureau, has estimated that SB 899 alone cut $3.3 billion from injured workers, and is estimating that the 2004 cuts reduced costs 15%. “Two rounds of cuts to injured workers’ medical and disability benefits have transferred nearly $10 billion dollars from already-strapped injured workers into the bulging pockets of huge insurance companies,” said Art Azevedo, president of the California Applicants’ Attorneys Association (CAAA), whose members represent injured workers. “All across California injured workers are being cut off from medical care and left to live in pain. Yet no rate regulation of any kind has been included in the rounds of cuts, leaving insurers free to add to already-historic profit levels from 2003. It would be a travesty to allow insurers to keep the profits from cutting injured workers’ care. We need a rate rollback, stringent disclosure and prior approval of any rate changes.”
Californiaa Attorney Appllicants Association
MEDICARE: MEDICARE SECONDARY PAYER ACT
Medicare: New Developments and Their Implications for Workers' Compensation
An article discussing the practical and political impact concerning the interface between Medicare and workers' compensation that concludes "...the parties can no longerignore the demands of CMS to seek its pre-approval before settling cases involvingcertain individuals."
Edward M. Welsh, Workers' Compensation Policy Review Jan/Feb 2004
MEDICARE DISTRIBUTES NEW QUESTIONNAIRE TO DEVELOP CLAIMS
CMS has issued 3 NEW questionnaires to obtain information from attorneys and benenficiaries concerning claims.
The Medicare Secondary Claim Development Questionnaire
The Secondary Claim Development (SCD) Questionnaire is a Medicare Secondary Payer (MSP) questionnaire that is sent to obtain information about other insurers that may pay before Medicare. The SCD is mailed when a claim is submitted to Medicare with an explanation of benefits (EOB) attached, a self-report is made by you or your attorney identifying an MSP situation, or a third party payer submits MSP information to a contractor, or the Coordination of Benefits (COB) Contractor. This questionnaire asks:
--If you have other health care coverage based upon your current employment;
--If you are receiving black lung benefits, workers' compensation benefits, or treatment for an injury or illness for which another party could be held liable, or are covered under automobile no-fault insurance; and
--If you have other health care coverage based upon a family member's current employment.
When you return the SCD in a timely manner, you help ensure correct payment of your Medicare claims.
Samples of Questionnaires
THE ROAD TO INTEGRATED HEALTH CARE
Employers Pass the Buck on Rising Health Care Costs
Rather than dramatic health benefit overhauls, most employers have made modest changes, primarily by shifting costs to workers through larger premium contributions or higher out-of-pocket costs to fill a prescription or see a doctor, according to a new HSC study.
Employers Pass the Buck on Rising Health Care Costs
Benefit Changes Include Increased Patient Cost Sharing and Less-Generous Family Coverage Policies
"Increased patient cost sharing appears to be employers' default plan, but most lack confidence that this strategy alone will provide a long-term solution to escalating health costs," Ginsburg said.
Center for Studying Health System Change
It blocked a deal that would have made it more difficult to unload asbestos on the developing world. It bought scientists and column inches in national papers. And it is killing hundreds of thousands each year. Hazards exposes the global asbestos industry's desperate battle for survival - at any price.
Oversight hearing on the Energy Employees Occupational Illness Compensation Program Act (EEOICPA)