Monthly Archives: January 2013

Skilled Maintenance Services Can Be Covered by Medicare

Today’s post comes from guest author Jon Gelman from Jon Gelman, LLC – Attorney at Law.

A settlement was recently reached in a pending Federal Court case tht will benefit Medicare beneficiaries who require skilled services. The Centers for Medicare and Medicaid Services (CMS) will no longer require that a patient “improve” inorder to be entled to services. Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed January 18, 2011

“New policy provisions will state that skilled nursing and therapy services necessary to maintain a person’s condition can be covered by Medicare.”

See: “Settlement Reached to End Medicare’s “Improvement Standard”

Read more about Social Security

Aug 11, 2012
The Social Security Administration has added to its list of compassionate allowances a pulmonary condition that has been identified as arising out of exposures to burn pits fumes and dusts in Iraq and Afghanistan.
 
Aug 03, 2012
“If a worker becomes eligible for both workers’ compensation and Social Security disability insurance benefits, one or both of the programs will limit benefits to avoid making excessive payments relative to the worker’s past …
 
Aug 13, 2012
An employer cannot stop paying workers’ compensation benefits merely because the injured worker was awarded Social Security Disability benefits. In fact, the premature termination of temporary disability benefits was …
 
Nov 03, 2012
The Social Security Administration has added to its list of compassionate allowances a pulmonary condition that has been identified as arising out of exposures to burn pits fumes and dusts in Iraq and Afghanistan.

 

 

North Carolina Workplace Deaths Lower in 2012

workplace fatalityOver the past decade, North Carolina has witnessed an ongoing decrease in the number of workplace fatalities. This past year (2012) there was a total of thirty-five reported workplace fatalities. In 2004, for example, there were 90 workplace fatalities.  According to the Department of Labor, the Occupational Safety and Health Division has been working with the state’s most hazardous industries to prevent deaths on the job. However, North Carolina continues to have one of the highest unemployment rates in the country at 9.2 % (December 2012) and with fewer jobs there are obviously fewer chances of an accidental death on the job.

According to the National Council for Occupational Safety the number of fatalities may be artificially low. In a report published in April of 2012 entitled “North Carolina Workers: Dying for a Job,” the National Council for Occupational Safety alleges that the N.C. Department of Labor’s “report of occupational fatalities greatly understates the true extent of the problem.” (http://www.coshnetwork.org/north-carolina-workers-dying-job). The report further states that the listed fatalities “include only those cases that the state OSHA program investigated” and that their internal analysis found that about thirty additional deaths occurred in 2011. The National Council for Occupational Safety then recommended stricter deterrents to promote safe work environments, imposition of more penalties as permitted under the current statutes, as well as a special emphasis program to protect Hispanic workers.

Let’s hope that on the job fatalities continue to drop in 2013, but beyond “hope” the best way to insure a continued decrease is to make all employees and employers aware of potential life threatening dangers and then enforce compliance with safety standards.

PTSD and Police Officers at the Newtown Massacre

First responders may develop PTSD after a traumatic event.Post-Traumatic Stress Disorder (PTSD) is a type of anxiety disorder that can occur after a person has seen or experienced a traumatic event that involved the threat of injury or death. In civil war battles a soldier may be sitting next to his best friend when a cannonball takes off his friend’s head. The horror of such events put some soldiers out of action. Similarly, police officers have a higher incidence of PTSD/Anxiety Disorders than the general public due to the gruesome scenes and situations that they witness in their occupation. Classic symptoms of PTSD fall into three main categories: (1) reliving the event (such as nightmares and flashbacks); (2) avoidance (including feeling detached, numb, and avoiding things that remind them of the event); and (3) arousal (including difficulty concentrating, startling easily, and difficulty falling asleep).

Some of the police officers who responded to the shootings in Newtown, Connecticut are suffering from PTSD, calling it the worst crime scene they ever walked into. They are suffering from severe emotional distress and shock and have been unable to return to work due to the trauma they witnessed. Unfortunately, PTSD is not covered by workers’ compensation in Connecticut. Therefore they have been forced to use vacation and sick time to cope with the situation.

Our law firm has represented multiple police officers who have developed PTSD as a result of the gruesome scenes and situations they have been involved in at work. Fortunately, PTSD may qualify as an occupational disease under North Carolina workers’ compensation law. Hopefully the Connecticut legislature will amend their statutes in light of the school shootings to help these police officers get medical care and get back to work as quickly as possible.

The SMART Act and Workers’ Compensation

United States Congress

Medicare should not pay medical bills that are the primary responsibility of a third party. When they do, they want to be reimbursed, and all parties understand that concept, but the problem is the lengthy delays and lack of due process. The SMART Act, which was signed into law by President Obama on January 10, 2013, amends and reforms the Medicare Secondary Payer Act to improve the reimbursement process. It is located in Title II of H.R. 1845 and entitled “Strengthening Medicare Secondary Payer Rules.”

Section 201 requires CMS to maintain a secure web portal with access to claims and reimbursement information. Payments for care made by CMS must be loaded onto the portal within 15 days of the payment being made. The portal must also provide supplier or provider names, diagnosis codes, dates or service, and conditional payment amounts. Moreover, the portal must accurately identify that a claim or payment is related to a potential settlement, judgment or award. After several steps, the parties may download a final conditional payment amount from the website. If there is a dispute over the conditional payment amount, CMS must respond/resolve the dispute within 11 days or the proposed resolution by the claimant/applicable plan will be deemed accepted. In terms of appeals, CMS must draft regulations that give applicable insurance plans limited appeal rights to challenge final conditional payment amounts. This process will go into effect around April of 2013.

Section 202 states that by November 15th of each year (beginning in 2014), CMS is required to calculate and publish a threshold for liability claims. If an amount owed is under that threshold amount, CMS is barred from seeking repayment.  Section 205 states the statute of limitations for conditional payment recovery by CMS is three years after the receipt of notice of a settlement, judgment, award, or other payment made.

The SMART Act applies to workers’ compensation cases, so it is important to understand the law and how it will be applied in the future. Read it and follow its implementation closely.

“I’m In It for the Money!”

Today’s post comes from guest author Roger Moore from Rehm, Bennett & Moore.

Surprisingly, many employers and insurance companies actually believe workers hurt themselves on purpose or at the very least put themselves in positions where they think an injury is likely. We hear this a lot as a basis for not settling claims for existing employees. Employers are worried that it will encourage other employees to get injured as well. What does that say about the particular employer who believes this? Either they are downplaying lots of injuries or they truly believe employees are willfully getting hurt. 

The reality is that most of our clients come to us because their injury-related medical bills are not being paid or they’re not being paid for time off from work due to their injury.

In this age of limited, and in some cases very limited, workers’ compensation benefits, you would have to be an imbecile to actually believe people are willingly causing permanent injuries to themselves to cash in on the “windfall” that is workers’ compensation. Who would honestly trade even thousands of dollars for a lifetime of uncompensated pain and suffering? The reality is that most of our clients come to us because their injury-related medical bills are not being paid or they’re not being paid for time off from work due to their injury. The vast majority of them don’t even ask how much they could get for their injuries in their initial meeting with us, as I’m sure is the case with most workers’ compensation law firms. 

This is one of a long line of personal-injury myths perpetrated by the insurance industry to make filing a workers’ compensation claim a stigma. It’s similar to the one about “if you file a claim our premiums will go up and they’ll have to shut down the plant.” Shouldn’t the question really be: are we requiring too much physically of our employees, and if so, what can we do to make things safer? Instead, Continue reading

Breast Cancer Linked to Workers' Exposure at Semiconductor Factory

Today’s post comes from guest author Jon Gelman from Jon Gelman, LLC – Attorney at Law.

A semiconductor plant worker, who had been exposed to solvents and radiation while working 5 years at a semiconductor factory in South Korea has been held to have suffered an compensable disease related to her exposure at work. The 36 year old women was employed between 1995 and 2000 at plant. Three years after contracting breast cancer she died. Workers’ Compensation benefits were awarded.

Recent studies have associated exposure to solvents as an increased risk factor for breast cancer. 

“Endocrine disrupting chemicals and carcinogens, some of which may not yet have been classified as such, are present in many occupational environments and could increase breast cancer risk. Prior research has identified associations with breast cancer and work in agricultural and industrial settings. The purpose of this study was to further characterize possible links between breast cancer risk and occupation, particularly in farming and manufacturing, as well as to examine the impacts of early agricultural exposures, and exposure effects that are specific to the endocrine receptor status of tumours.”

Breast cancer risk in relation to occupations with exposure to carcinogens and endocrine disruptors: a Canadian case–control study
Environmental Health 2012, 11:87 doi:10.1186/1476-069X-11-87 Published: 19 November 2012

 

Report: Poor Health Costs Cost U.S. $576 Billion Yearly

The U.S. loses more GDP to poor health than Sweden’s total GDP

Today’s post comes from guest author Nathan Reckman from Paul McAndrew Law Firm.

The Integrated Benefits Institute (IBI), a nonprofit health and productivity research organization for businesses, recently reported that poor health costs the U.S. economy $576 billion per year. Of this amount:

  • $227 billion is lost due to sick days or reduced productivity due to illness,
  • $232 billion is spent by employers on medical and pharmacy treatments, and
  • $117 billion is spent on workers’ compensation and short- or long-term disability wage replacement.

To give you a sense of the scale of this loss, it is larger than the entire gross domestic product (GDP) of all but the top 20 countries. Our $576 billion loss dues to poor health costs would fall directly behind the GDP of Saudi Arabia (2011 GDP: $577.6 billion) and in front of the Swedes (2011 GDP: $538.2 billion). For comparison, the U.S.’s $15,090 billion GDP was the largest in the world, followed by China at $7,298 billion.

…for every $1 employers invest in improving their employees’ health and wellness they save $3…

Sean Nicholson, Ph.D., quoted in the IBI report, has stated that for every $1 employers invest in improving their employees’ health and wellness they save $3 (quite a good return on their investment!). As wisely pointed out by IBI’s President, Thomas Parry, Ph.D., this report puts employers on notice that their investment in workers’ health and wellness will benefit both the workers and their employers.

This report, in addition to  pointing out the dual benefits posed by increased employer investment in their employees’ health and wellnes, points out one of the important choices facing our country’s healthcare system.

Source for 2011 GDP information: CIA World Factbook

Injuries Arising Out of Employment – Is the Concept Shrinking?

Today’s post comes from guest author Tom Domer from The Domer Law Firm.

A headline article noted the following: “Virginia Court: Waiter’s choking on quesadilla did not arise out of employment.” The Virginia Court of Appeals ruled a waiter who was injured while working attempting to swallow a piece of quesadilla too big for his esophagus cannot collect worker’s compensation benefits. The injury caused an esophageal perforation and collapsed lung. The Court, however, found the injury was not as a result of an actual risk of employment. The claimant worked as a host and waiter at a local T.G.I. Friday’s restaurant and part of his work responsibilities was to make food recommendations. T.G.I. Friday’s conducted food tasting demonstration programs to introduce menu items to its staff so the staff could describe the taste to customers and recommend these items. The tastings were provided free to the employees and while the employees were on the clock. T.G.I.Friday’s required attendance but no employee was forced to eat anything they did not want to eat. The Worker’s Comp Commission found that since the worker was not required to taste anything, the injury did not arise out of an actual risk of his employment.

A causal connection must exist between employment and the risk of harm, demonstrating it would be more probable that the injury would not have occurred under normal circumstances of every day life outside the employment situation.

The Wisconsin Worker’s Compensation Division and courts would likely have come to a different result. The very first case I ever tried in the 1970s concerned a firefighter who broke a tooth on a cherry pit while eating dinner at the fire house. To be compensable in Wisconsin, the accident or disease causing an injury must arise out of the employee’s employment. While the “course of employment” deals with the time, space, and intent, “arising out of employment” is related to the origin or cause of the accident so the risk of a particular accident might have been contemplated by a reasonable person when entering the particular employment. Establishing a causal connection between the injury and employment is an essential element of compensability. A causal connection must Continue reading