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Location: Fort Myers, Florida, United States

People tell me that my sarcasm and cynicism will get me into trouble some day. We'll see.

Saturday, April 07, 2007

Singing the Worker's Compensation Blues

Have you ever had to deal with Worker's Compensation? Specifically, medical benefits? My wife and I have had to work with Worker's Comp a few times over the years, and it has ALWAYS been a hassle.

Here's our typical circumstance. Say I have an injury at work - usually nothing major - a small puncture wound for example. Nothing like being beaned by a falling pallet or something. Boss sends me to the Emergency Room. Typical fare on that - wait three hours, finally see the doctor, some routine procedure and a Band-Aid fifteen minutes later and I am back to work.

Now the fun begins. Though I had specifically instructed the E.R. to point to my employer's Worker's Compensation insurance provider, supplied by my employer, sooner or later I have come to expect getting a bill from the hospital for services rendered.

The story's always the same. The hospital had forwarded my claim to my employer's insurer, but they never paid. Therefore, the balance due becomes MY responsibility. Now I know, once again, that I will be facing a six month painstaking dialog among myself, the insurer and the hospital.

The insurer will invariably claim that there is missing information - be it a signature from my boss, or some form from the hospital, or what have you. It then becomes MY responsibility to track down and acquire this missing link - and in the mean time, the hospital keeps sending me past due notices and death threats if I don't send them some sort of payment within the next thirty days. Well maybe death threats is a little exaggerated, or maybe not.

Eventually, the hospital claim is settled and the threats cease. Right around then is when one of us gets another injury.

The last straw

Something happened recently that made our previous excursions with Worker's Comp seem like a walk in the park. My wife injured herself at work a while back - nothing serious - just a nicked hand. Boss says, Why don't you go to the Emergency Room? Nah - it's not that bad, she said. No, really! We insist. So off to the ER she goes. No big deal - she was in and out in about ten minutes, (well, in and out of the examination room - she was in the waiting room for two hours.) The doctor trimmed away the exposed tissue and sent her back to work with a Band-Aid.

Though she never gave her home address, and had only given the provider information from her employer, she got a bill from the hospital anyway. Turns out they found her address from her medical records, as she had visited that hospital in the past for routine work. Anyway, the bill was for one thousand and seventy five dollars.

We had the usual runaround we have come to expect, but eventually we were "told" the bill had finally been paid. That is, until last week, when yet another bill arrives for two hundred and thirty eight dollars. Here we go again, we said. She submits the bill to her boss, and he calls the insurer. Later, he reports that the insurer investigated the statement and had determined that the amount was the difference between the total hospital charges and the negotiated rate the Worker's Comp insurer pays for the services provided. She was also told that the hospital will "write off" this charge, and the bill will be considered Paid in Full.

Normally this is where the average person would be relieved - I mean after all, no more bills, right? But in my mind, I thought it a bit aggravating that the hospital, who KNOWS they have negotiated a special rate with Worker's Comp, should be trying to squeak that last amount from the patient, (who technically should be responsible for NO amount - given that the coverage is supposed to be totally provided by Worker's Comp.)

So basically they are trying to convince the patient that there is still an amount owed, when in fact, there is none. The best analogy I can come up with is a car dealer who offers a construction company fleet rates for their trucks, and then tries to collect the difference from the truck drivers.

Though we ended up having the luxury of ignoring the bill for $238, because we started an investigation, I cannot help but to think of the times where a teacher or a single mother of three took food away from their families in order to pay a bill that was not even the hospital's to collect, in order to avoid late night calls from collection agencies and bad credit ratings. (I can hardly imagine a hospital calling a collection agency for a past due payment on amounts not even legitimately owed - oh wait - I can.)

The practice of trying to recoup the difference between standard and negotiated rates is not limited to Worker's Comp claims. I had similar beefs with some hospitals while dealing with claims through my employer's medical insurance which also utilized negotiated rates.


Worker's Compensation is an important benefit that has its place in the American workplace. However, as a government program, there are plenty of opportunities for abuse, in this case from the hospitals. I suspect there are two driving forces behind the hassle we see whenever we find ourselves facing a claim. One, the Worker's Comp insurer your employer chooses hopes that you will get so sick and tired of the hassle that you will submit the bills through your existing health insurance policy, or better yet, out of pocket. Some health insurers allow that, but others force you to go through Worker's Comp if the injury happened on the job. And two, I think hospitals know this and have found themselves getting nowhere if they only deal directly with the insurers, so the hospitals have found that if they get the patient involved, and threaten collection and credit exposures, then the patient will work to resolve the issues to preserve their good credit.

There's even a theory that these entities are plotting against the employee to make him more responsible at work so as not to get injured and have to deal with all this. Yeah, that's right. We're just clumsy and looking to get time off of work.

But why does it have to be that way? I'm all for reform that can ease the process of recovering from job injuries (the financial recovery, not the physical.) And I am certainly in favor of any change we can see in keeping hospitals honest enough to stop trying to collect from the patients differences they have agreed upon with the insurance companies and are not actually owed by anybody.



Blogger Freddie said...

Ok. First of all, I worked on the side of the insurance companies Sarc. (Somebody has to do the dirty jobs, right?) And it wasn't easy. In fact, at that time, the companies were just starting to get very strict as to what they would pay for and what they wouldn't. They had started sending out Guidelines at the onset of a case which we had to agree to follow in order to get/keep their work. And if the guidelines weren't followed, they would return our bills rejecting certain portions based on things that had been done which were expressly prohibited in their guidelines. Then they started requiring that we bill in very specific ways (no block billing, all even time increments, every entry had to include a special "code", etc.) and they would reject and make us fix and resubmit bills that weren't submitted in their proper, approved format. It seemed they were doing everything possible to "trim the fat" from their expenses in all areas.

Yes, they were a PITA to deal with for a long time, but once we got accustomed to doing what they said within the time frames/guidelines they required, things smoothed out again. I used to hate dealing with insurance companies too but I've learned that if you do things the way they want, when they want them done, it's not really so bad.

Friday, June 06, 2008 8:15:00 AM  
Blogger Freddie said...

Now, I think many hospitals have yet to learn this. They're big ol' "red tape" machines. I too had a problem like the ones described in your post (not worker's comp. but health insurance-related). I had been in the hospital for an overnight stay in the Intermediate ICU, and then a few months later we changed our insurance carrier. Nearly A YEAR later I started getting bills from the hospital for some $600 in connection with that IICU stay and, of course, the time period for the hospital to submit bills to my former insurance carrier had LONG since past. I ignored their notices for a while because I knew it wasn't my responsibility to pay, but when they threatened to turn it over to collections I finally had to break down and send the hospital a detailed letter telling them why/how it wasn't my responsibility and that I wasn't going to pay it. Their response? Basically: "From a review of your records, we see that you and your family are regular patients at our facility and in order to ensure a good working relationship with you in the future, we'll drop it."

I've also seen some major abuse against the insurance companies in relation to worker's comp. The "professional plaintiffs", who manage to get injured over and over again, at employer after employer, who keep trying to get that BIG settlement from the insurance companies. When you think about the amount of money the insurance companies have to spend defending themselves against that kinda crap... Seriously. There were people who claimed they couldn't walk, lift or stand, and blah blah blah, yet we'd hire surveillance and catch 'em coming strolling out of malls loaded down with packages, moving furniture out of their apartments, or out on the golf course enjoying their (doctor ordered) time off work – stuff like that.

My best advice? Make sure you know and understand what your insurance companies expect from you, and do it. Keep good records and timelines and fight back if/when they try to stick it to you.

Friday, June 06, 2008 8:15:00 AM  

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