SB899 - Nothing New Here - Medical Treatment

Saturday, May 22, 2004 | 0

The following article has been adapted from an article written by national workers' compensation expert and employer consultant, James J. Moore. Though originally written from an employer perspective, the editors felt that the article provided particular insight relevant to physicians practicing industrial medicine.

SB899 - Nothing New Here - Medical Treatment
by James J Moore, AIC, MBA, ChFc

When reviewing SB899 from a national perspective, the statutes are nothing new. The law exists in other states that one may find surprising. As most of SB899 centers around medical networks, I will cover the topic in some detail.

One area critical to the Medical Provider Networks is the rules that are to be established by 11/1/04 for these networks. I have seen this type of legislation/rules make or break a state's WC system.

National Comparison of Medical Provider Networks

California is not the only state that will have a list of medical providers selected from a list by the employee. The states that allow the employee to make a medical choice of treatment after a specified time are:

- California (until 1/1/05)
- Maine
- Michigan
- New Mexico
- Pennsylvania

Depending on the rules and regulations that will be promulgated by 11/1/04, CA will either be a state that allows the employee to select from a list prepared by a state/quasi-state agency or selection from a list maintained by the employer. My understanding is that it will be the latter.

The states that allow an employee to choose from a list prepared by a state agency are:

- District of Columbia
- New York
The states that allow a selection from a list maintained by the employer:

- California (as of 1/1/05) - depending on rules promulgated by 11/1/04
- Georgia
- Tennessee
- Virginia

I am of the opinion that the maximum claims cost savings exist in states that allow the employer to choose the initial treating physician. Those states are:

- Alabama
- Florida
- Idaho
- Indiana
- Iowa
- Kansas
- Missouri
- New Jersey
- North Carolina
- South Carolina
- Utah
- Vermont

The following passage is one of the "Four Secrets to Saving WC $" that I wrote almost 10 years ago. The message still holds true today.

Dr. Network - THIS is the most critical part of any WC claim without question. One very important point to remember is the Industrial Boards and Commissions in each state that oversee WC claims consider the medical providers, especially the treating physician, as the only impartial parties/witnesses in the WC claim. Some states require that a medical panel be available to all employees so that all employees have immediate and proper medical care. All employers in all states should have a panel of physicians. Some states allow the employer to have the choice of medical providers for the employees, while others allow the employee to choose their own physician. However, studies have shown that employees in states that allow the employee to choose the physician will usually attend the paneled physician.

The treating physician makes the determination of what medical costs will be incurred, the length of time the employee is out of work, and if the employee has any permanent disability. A good industrial-minded physician in the local area is very important to the employer's WC program. I recommend that employers select a walk-in clinic or an urgent care clinic to initially treat all injuries. A large number of WC urgent care centers are cropping up around the US.

The most important physicians for the more serious injury are the level two physicians. These physicians are usually surgeons (Orthopedic, Neurosurgeon, etc). The level-one physicians should know who the employer's preferred level two physicians are before a referral is made. If an injury is very serious, the employee should be taken to the emergency room at the nearest hospital. It behooves the employer to know the nearest industrial-minded orthopedists, neurologists, orthopedic surgeons, and neurologists in their general area (within 150 miles). The physician network often has to be expanded beyond the local area due to availability of medical providers.

Multiple Opinions

The main area of SB899's medical provider networks that deviate from the norm with the states that have the same medical rules is allowing the employee multiple independent exams if they want a different opinion. Most of the other states in the same category allow the employee to have one additional exam. The employee must keep treating with the original physician. Allowing a large number of medical opinions will take time to occur. If an employee disagrees with all three opinions in the medical provider network, a fourth opinion can be sought outside of the medical provider network. That is the most opinions I have seen allowed in these states.

Medical Provider Network Deadline

One of the most disconcerting areas of the Medical Provider Networks is the deadline to have a treatment network in place. The rules for the networks will likely be promulgated by 11/1/04. That will leave employers 2 months with multiple holidays to have a network in place. This will occur when every employer is attempting to establish a network. No employer should put this on the "back burner".

Article by James Moore, AIC, MBA, ChFc and President of J&L Risk Mgmt Consultants, Inc. James can be reached at jmoore@cutcompostcosts.com, at www.cutcompcosts.com, or at (800) 813-1386.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.