Work Comp and the ER Doctor Part 2

Sunday, September 29, 2002 | 0

In our last article we took a look at the great diversity of workers' compensation cases that the Emergency Room Doctor (ED) sees. Now we'll discuss how work comp systems differ from other systems - your understanding of how workers' compensation differs is important not only in how you treat the patient, but can have an impact on the ultimate course of the patient's workers' compensation case. The old saying that first impressions are often the most important impressions is particularly applicable in workers' compensation.

Comp insurance and law differ in several very important ways from other forms of medical/disability insurance and medical-legal practice. Years ago,before workers' compensation became mandatory for employers, injured and disabled workers had to bear all costs of medical care and rehabilitation. Their only recourse was to sue their employers for negligence, a costly and very time consuming process, and not always legally successful because of the burdens of proof necessary in the civil justice system. It was not unheard of for injured workers and their families to go destitute as all forms of income dried up, medical bills mounted, and the injured worker unable to work. Employers had increasing litigation costs, and the threat of huge penalties.

Workers' compensation was instituted as a compromise to limit the damage to both parties by getting medical care and compensation to the injured quickly, and by limiting the damages that could be assessed against an employer. Though details the of comp insurance and law differ between the states, all have certain principles in common:

The vast majority of states require employers to carry workers' compensation insurance. This insurance provides payment of medical care, rehabilitation, and income protection for eligible employees that are injured or sustain an illness on the job or as a result of their job. This insurance is separate from other employer-paid health insurance and employers' premium costs frequently are passed to the public through increased prices for goods and services.

To be eligible for work comp coverage, the employee's injury or illness must have arisen out of, or be related to, the course of employment. Preexisting conditions that are worsened by job-related events and activities also may be covered. There are exceptions such as injuries incurred as a result of intoxication. In work comp parlance, this is commonly referred to as "AOE/COE" (acronym for arising out of employment or in the course of employment).

Work comp insurance is no-fault insurance, which means that it doesn't matter HOW the employee got hurt, just the fact that the employee has an injury or illness related to his work is enough. In return for this coverage, employees relinquish the right to sue their employers for damages.

Benefits (consisting of medical care and income protection) are to be promptly made available to the worker (and his or her medical providers).

Work comp insurance also differs notably from other medical insurance in that the insurer (or the employer if self-insured) is liable for income replacement during any period of disability as well as medical costs, and this liability is open-ended, in some cases for the balance of the injured worker's life. The goal of workers' compensation is to return the employee to full duty as expeditiously as possible - insurers are motivated to optimize functional outcomes rather than to minimize direct medical costs. This benefits all parties to a work comp claim, and in particular the employee because often work comp cannot adequately replace lost income.

An ED physician often initiates the work comp process for the injured worker, and it is his or her responsibility to produce the best medical outcome and quickest return to the fullest possible function. Ideally, this outcome is satisfactory to the patient, physician, employer, and insurance company. While the work comp system is subject to abuse, like any other entitlement system, it can be extremely effective in mitigating the effects of work-related injury and illness.

Next we'll take a look at improving care and service delivery to workers' compensation patients in the Emergency Department.

Authored by Denyse Shaw of Comp Pro Insurance Services, matching vendors to the specific needs of administrators and carriers. She can be reached at 916-944-7870, or by e-mail at denysekshaw@earthlink.net.