Category Archives: Medical Benefits

Settling your workers’ comp claim now? Do this immediately.

If you’re in the process of resolving your workers’ compensation claim (or have settled it recently), please make sure you have health coverage going forward to cover your future treatment!  The deadline to sign up for a plan under the exchange created by the Affordable Care Act is today (it was extended from 12/15/16), so act fast!  Here’s a link to help you:  www.healthcare.gov

 

Can I get paid for taking care of my sister by workers’ comp in Georgia?

We currently have a very sad case in which the injured worker suffered severe brain trauma and is unable to take care of herself without assistance.  So, her younger sister has been kind enough to step into the role of non-medical attendant caregiver during the day to make sure the injured worker can engage in activities of daily living.

man using braces to walk

The Medical Office Mgmt v. Hardee case offers us some guidance on this issue.  For hourly rates that non-medical attendant caregivers can get paid, see this link to the State Board of Workers’ Compensation medical fee schedule (specifically, this sheet).  Currently, such caregivers–including family members–can get $10.50/hour for up to 12 hours a day for such care.

The attendant care needs to be medically necessary to effect a cure, provide relief, or restore the injured worker to suitable employment under O.C.G.A. 34-9-200(a) and be prescribed by the authorized treating physician in order for the workers’ compensation insurer to cover it, so if you find yourself in a situation where you require such care after an injury at work, or if you’re the person providing such care for a loved one’s injury at work, talk to the treating doctor about making this referral or prescription, so you can cover some of the costs your being out of work for several hours a day to care for your loved one!  Too many folks do not know to utilize this section of the Georgia Workers’ Compensation Act and its interpreting case law, and I find many spouses or other family members and friends are providing these services by necessity without getting reimbursed for their time.  Don’t let that be you!

Image courtesy of “stockimages” at FreeDigitalPhotos.net

How a Workers’ Compensation Adjuster’s Intentional Delays Killed a Man

How many times could a company with a homegrown, wholesome name like Ralph’s Grocery Co. turn a blind eye to the medical needs of an injured employee? According to the California Workers’ Compensation Appeals board, 11 is the lucky number.

Sedgwick-CMSThe trouble began in December 2003, when Charles Romano sustained an injury to his left shoulder and cervical spine while stocking the shelves of Ralph’s Grocery Co. in Camarillo, California. Two years after the initial injury, Romano finally received the authorization required to proceed with surgery. Romano’s shoulder was healed, but he contracted a serious staph infection as a result of the procedure. Once healthy and hardy, Romano suffered both pulmonary and renal failure, followed by partial paralysis.

And what did Ralph’s Grocery Co. and its third party claims adjuster do once they realized that Romano had contracted an antibiotic-resistant staph infection, more commonly known as MRSA? As Romano suffered from this debilitating, multi-system illness, Sedgwick CMS delayed eleven requests for authorization and reimbursement.

But wait–it gets worse. Not only did Sedgwick CMS fail to deliver fair reimbursement in a timely fashion, they also ignored a judge’s direct order to provide Romano with the intensive care that he needed until his medical bills had reached a grand total of $24,000 a day.

Charles Romano was 47 years old when he died from cardiorespiratory arrest, respiratory failure, and pneumonia resulting from an untreated MRSA infection. In the years prior to his death, Romano was treated at five separate facilities; Sedgwick CMS either delayed or refused to pay any of the accompanying medical costs, even after Romano was awarded further medical treatment by the California Workers’ Compensation Appeals Board. This appalling conduct continued up until Romano’s death, when Sedgwick CMS denied authorization for his final stay at Community Memorial Hospital.

Perhaps most distressing is the fact that Sedgwick CMS contends that they cannot be penalized for eleven instances of “unreasonable delay” because the applicant is now deceased. This attitude certainly conflicts with the heartfelt, apologetic statement made in response to the threat of prosecution.

After the untimely death of Ralph’s Grocery Co. employee Charles Romano, friends and family have rallied to his cause. In June 2013, longtime friend Sid Freeman joined forces with several members of the Central Coast Chapter of the California Applicant Attorney Association. After going public with a brief news conference, Freeman went on to file a letter with District Attorney Greg Totten pushing for the criminal prosecution of the third party claims administer Sedgwick CMS.

At Moebes Law, we are outraged by this blatant disregard for employee health and welfare. If you suffer from a workplace injury, don’t let your case get swept under the rug — contact us for a free consultation today.

Does workers’ compensation pay more for medical care than group health insurance?

A recent report by the Workers Compensation Research Institute indicates that workers’ compensation plans have to pay out more on the whole for treatment than employer-sponsored group or private health plans. The independent think tank is based in Cambridge, Massachusetts and looked at sixteen states for this study. In over two-thirds of them, medical payouts on workers’ comp procedures were much higher than the exact same procedures for private plan holders. They sometimes climbed to greater than fifty percent -a startling figure, for sure– more, in fact.

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Research was based on data from medical care given in 2008. Richard Victor, executive director of WCRI, believes these findings will be of interest to insurance and health care professionals, union leaders, workers, and state officials.

“In every state I know of, they are interested in what they can do to increase job creation,” Victor said. “If workers’ compensation costs are unusually high, that puts that state at a disadvantage.”

Workers’ compensation insurance is purchased by employers to provide benefits to employees who become ill or injured while on the job. Coverage includes both medical costs and a partial replacement of an injured worker’s income while they are out of work. The premium employers pay for this insurance is based on the size of their payrolls as well as the volume and degree of severity of injuries and illnesses in their particular industry.

There are two ways that payment to providers can be approached: Regulated and unregulated. In the regulated scenario, amounts paid out on workers’ compensation claims are often regulated by states or are negotiated between insurers and health care providers. In unregulated states there are no set fee schedules for procedures. In three of the four unregulated states -New Jersey, Iowa, and Virginia– costs associated with workers’ comp treatments were extremely high.

Knee and shoulder injuries are some of the most common injuries in workers’ compensation cases. In reviewing these types of cases, the WCRI found that the average workers’ comp payment for shoulder surgery in New Jersey was $7,323 while group health plans paid only $4,583 on average, making the group plan procedure 37 percent less. Knee surgery via workers’ compensation insurance cost $5,547, 42 percent higher than payments through group health plans, to include the co-payments and deductibles paid by patients themselves.

According to a separate study by Oregon’s department of consumer and business services, New Jersey ranked seventh-highest among all fifty states for workers’ compensation premiums paid by New Jersey employers last year.

In Virginia and Iowa, shoulder surgery was more than twice the group health average cost of $5,279 and fifty percent more for workers’ compensation procedures at $8,586, respectively.

In several states where hospital fees are not regulated, workers’ compensation insurers have less bargaining power in price negotiations with hospitals than private group insurers, which lay claim to a much larger portion of the market than workers’ comp insurers. This is a contributing factor to high costs.

Massachusetts and California, which are both states with fixed payment amounts that hospitals can charge in workers’ comp cases, payments were lower than payments made via group health plans. Shoulder surgery in Massachusetts was an average of $2,636 under workers’ comp, while group health plans for the same surgery paid out an average of $4,592. In California, workers’ compensation payments were an average of 16 percent lower than group plans.

Hopefully, studies such as these can be used to 1) further evaluate and adjust medical costs in workers’ compensation claims and 2) encourage quality physicians to “take on” workers’ compensation claimants as patients!

The Price is Wrong for Gameshow Contestant Caught Committing Workers’ Comp Fraud

According to media spin, in more cases than not employees are out to get over on their bosses and workers’ comp insurers in whatever way they can. Mainstream media would have you believe that claimants are irresponsible, greedy, and looking for a ‘free ride.’ As an experienced Atlanta workers’ compensation attorney, I can assure you that this is just not the truth. Clients come to our practice sick, in pain, and fearful for their financial health. On the whole, they don’t want to be out of work, they don’t want to have to deal with the workers’ compensation system, and they aren’t looking for a handout.

While I typically don’t like to pay too much attention to cases of workers’ compensation fraud by employees, sometimes there is just a workers’ compensation case that is too comical or ludicrous to ignore. After having said that, I’d like to introduce you to the one involving Cathy Wrench Cashwell.

Ms. Cashwell is a former postal employee who claimed that a shoulder injury incurred on the job in 2004 left her unable to perform her job duties, which consisted of lifting mail trays into trucks. Then, in September of 2009, she went on the game show ‘The Price Is Right,’ where she was observed doing something shocking: Spinning the ‘big wheel’ that is a hallmark of the popular gameshow.

Cashwell was observed spinning the wheel two times during her appearance. According to the indictment filed against her workers’ compensation claim, Cashwell “…raised her left arm above her head and gripped the handle with her left hand.” On her second spin, the indictment says, she “…raised both arms above her head and gripped the same handle with both hands.”

price is rightWhile those two spins by themselves may not have been enough to do her in, they were more than enough to raise the suspicions of investigators, who began gathering evidence of her lack of injury.

The indictment recounts an incident in August of 2010 when Cashwell and her husband went ziplining as part of a Carnival Cruise vacation. It also notes that she carried heavy items like grocery bags and furniture on multiple occasions in 2011. In short, the indictment (which was filed last September) accuses Cashwell of lying about the extent of her injuries.

When she renewed her claim for her injuries as recently as 2011, Cashwell again stated that her injuries hindered her ability to bend, reach, grasp, sit, and engage in other physically demanding activities that would have been required of her in her former job as a postal worker.

Cashwell pled guilty to fraud in federal court earlier this month, and her sentencing is scheduled for September.

If you’re going to get hurt at work in Georgia, do it before July 1, 2013

Starting Monday, July 1, 2013, workers’ compensation medical benefits will be drastically reduced for injured workers in Georgia. GA House Bill 154, passed by the Georgia General Assembly a few months ago, will be effective next week. One of its provisions is that medical benefits for injured workers will stop at 400 weeks (like income benefits do), unless the case is deemed “catastrophic”  under O.C.G.A. 34-9-200.1(g).

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I have several current clients whom this would have negatively affected were it in place at the time of their injuries.  Often, such clients are having to take expensive medications and will need them indefinitely, but they are able to work (and are doing so), so their cases aren’t “catastrophic” in nature.  Should an injury like theirs occur next month, the injured’s medical needs will not be fully met by the party responsible for the injuries.

Other provisions of the bill will help Georgia’s injured workers, including:

1.  the maximum rate for temporary total disability will increase from $500/week (2nd lowest rate in the nation) to $525/week (still very low).  The maximum rate for temporary partial disability benefits will rise from $334/week to $350/week.

2.  mileage and fees associated with medical travel will be due in 15 days instead of the current 30 days.

3.  interest rates on lump sum advances fall from 7% to 5%.

While the title of this post is written with a humorous bent to it, I very often hear from potential clients that they are working through moderate to severe pain every day, but are afraid to report their pain to an employer, for fear of losing their jobs (or falling out of “good graces” with their bosses).  If this is your current situation, I would highly recommend that you go ahead and report your on-the-job injury–repetitive or acute in nature–as soon as possible, before your potential medical care for such injuries is drastically reduced. Contact my Atlanta workers’ compensation firm.

 

 

Does the insurance company have to settle my workers’ compensation case?

The workers’ compensation insurer does not have to settle your workers’ comp claim in Georgia, but it usually will at some point. Because an accepted workers’ comp claim (i.e., one in which you have received disability benefits) means you are owed medical care related to your injury for the rest of your life, absent some subsequent accident or injury, most insurance adjusters want to “close out” their files at some point to avoid a change in condition for the worse popping up years in the future after you’ve reached maximum medical improvement (MMI).

So, while your claim doesn’t have to settle, and you are not owed a settlement, and you can’t force a settlement, it’s normally in the best interest of all the parties to eventually settle and close an open workers’ compensation claim in Georgia.

If your claim has been offered closure and a settlement by the workers’ comp adjuster, and you’d like a legal opinion regarding its adequacy, feel free to contact my Atlanta workers’ compensation law office:

Moebes Law, LLC
3535 Piedmont Road NE
Building 14, Suite 410
Atlanta, GA 30305
(404)354-5432