Category Archives: Medicare

“Cost-Shifting” Exposed: How Injured Worker Medical Care Decisions Are Made (And Who Pays)

Today’s post comes from guest author Catherine Stanton, from Pasternack Tilker Ziegler Walsh Stanton & Romano.

Medical coverage is a topic on everyone’s mind. Obamacare, while controversial, has started a real dialogue in this country regarding health care. Regardless of whether you are in favor of the current law, most Americans want affordable health care for themselves and their families.

Many employers pay for a substantial amount of their workers’ premiums as a benefit to them, and take this into consideration when making salary decisions due to the high cost, thereby leaving workers to pay for all or some of their medical coverage. Sometimes insurers pay for benefits that are not their responsibility because the proper entity refuses to pay. This is known as cost shifting. As a practitioner in the field of Workers’ Compensation, this idea of cost shifting has become an all too common occurrence. 

By way of background, as a result of social reform, most states enacted some form of Workers’ Compensation legislation in the early 20th Century. In exchange for timely payment of medical and indemnity benefits, workers gave up the right to sue their employers. In 2007 in New York, there was a series of further reforms that led to compromise between labor groups, the insurance industry and the Business Counsel. There was an increase in the amount of weekly benefits to injured workers to conform with the State average weekly wage (now a maximum of approximately $800 per week) in exchange for a limit on the amount of weeks an injured worker is entitled to receive these benefits.  Additionally, medical treatment guidelines have been introduced with the premise that they would streamline costs and get injured workers faster and more effective medical care. These guidelines are based upon the principles of Evidence Based Medicine (EBM), which is the use of clinical trials and data to determine whether a specific treatment should be recommended for a specific diagnosis.  It is sometimes referred to as “cookbook” treatment. 

In New York, the Court of Appeals recently ruled by a 4-3 margin that any treatment not specifically included and pre-authorized is presumptively unnecessary. In other words, if a treatment requested is not within the medical treatment guidelines, it is denied. This takes the decision making out of the hands of the treating physician who is really in the best position to determine what treatment would be most beneficial for patients. In order to overcome this presumption, the doctor now must engage in what has been seen in most cases as an exercise in futility to request a variance to overcome this presumption.

The New York Committee for Occupational Safety and Health (NYCOSH) reported that the New York State Workers’ Compensation Board received 202,643 variance requests in the first 10 months the guidelines were implemented. A quarter of the requests were rejected by the Board immediately. The rest can lead to protracted litigation. As a result, in many instances injured workers will now shift the cost to another party, such as their own private insurance, Medicare or even worse, pay for the treatment out of pocket. It is the path of least resistance. We all pay an additional price for medical costs borne by group health insurance carriers, Medicaid, and Medicare that should in fact be paid by Worker’s Compensation insurers. This cost shifting may increase Workers’ Compensation insurance profits, but it hurts both the employers’ and the employees’ bottom line. Injured workers don’t stop needing treatment just because their medical claim is denied. Someone has to pay for the cost of lost time and medical treatment. It is time that the proper party step up and take responsibility.

 

 

Catherine M. Stanton is a senior partner in the law firm of Pasternack Tilker Ziegler Walsh Stanton & Romano, LLP. She focuses on the area of Workers’ Compensation, having helped thousands of injured workers navigate a highly complex system and obtain all the benefits to which they were entitled. Ms. Stanton has been honored as a New York Super Lawyer, is the past president of the New York Workers’ Compensation Bar Association, the immediate past president of the Workers’ Injury Law and Advocacy Group, and is an officer in several organizations dedicated to injured workers and their families. She can be reached at 800.692.3717.

Workers’ Compensation Medicare Set-Aside Accounts and Supplemental Coverage

When an injured worker is a Medicare beneficiary due to age or disability, a Workers’ Compensation Medicare Set-Aside (WCMSA) account will often be required as part of a settlement  of their workers’ compensation claim.  The funds in a WCMSA are set-aside in order to pay for future medical or prescription drug services related to the work related injury, illness, or disease that would normally be covered by Medicare. Once the funds in a WCMSA have been used appropriately, then Medicare can start paying for Medicare-covered services related to the work-related injury, illness, or disease. The WCMSA cannot be used to pay for any medical items or services that Medicare does not normally cover.

Workers’ compensation insurance provides 100% coverage of medical treatment for accepted medical conditions. Medicare, however, requires an 80/20 sharing of medical costs. Without a Medicare supplemental (also called “Medigap”) insurance policy, the injured worker would be required to pay significant co-pays and deductibles.  Supplemental insurance is not required by Medicare, but may be advisable to cover the cost sharing required by Medicare, especially if the beneficiary has other medical conditions that are not related to the work injury, illness or disease. However, the premiums for such supplemental coverage cannot be paid out of the WCMSA funds.

While Medicare does not provide coverage for prescription medications, WCMSA funds can be used to pay for medications related to the work injury, illness or disease. If there is a likelihood that the injured worker will exhaust the funds in their MSA, then purchasing a Medicare Part D prescription drug plan may be advisable to prevent the injured worker from having to pay full price for their medications once the MSA funds are exhausted. However, the financial benefit of having this coverage should be weighed against the cost of plan (2013 national average was $30.00 per month) since the MSA funds cannot be used to pay for the plan itself.

 

For more detailed information about workers’ compensation MSAs and supplemental coverage, visit www.Medicare.gov.

 

Workers’ Compensation Medicare Set-Aside Accounts and Supplemental Coverage

Medical_Care_Card_USA_SampleWhen an injured worker is a Medicare beneficiary due to age or disability, a Workers’ Compensation Medicare Set-Aside (WCMSA) account is usually required as part of a settlement.  The funds in a WCMSA are set-aside in order to pay for future medical or prescription drug services related to the work related injury, illness, or disease that would normally be covered by Medicare. Once the funds in a WCMSA have been used appropriately, then Medicare will start paying for Medicare-covered services related to the work-related injury, illness, or disease. The WCMSA cannot be used to pay for any medical items or services that Medicare does not normally cover.

Workers’ compensation insurance provides 100% coverage of medical treatment for accepted workers’ compensation medical conditions. Medicare, however, requires an 80/20 sharing of medical costs. Without a Medicare supplemental (also called “Medigap”) insurance policy, the injured worker would be required to pay significant co-pays and deductibles.  Supplemental insurance is not required by Medicare, but may be helpful to cover the cost sharing required by Medicare, especially if the beneficiary has other medical conditions that are not related to the work injury, illness or disease. However, the premiums for such supplemental coverage cannot be paid out of the WCMSA funds.

While Medicare does not provide coverage for prescription medications, WCMSA funds can be used to pay for medications related to the work injury, illness or disease. If there is a likelihood that the injured worker will exhaust the funds in their WCMSA, then purchasing a Medicare Part D prescription drug plan may be advisable to prevent the injured worker from having to pay full price for their medications once the WCMSA funds are exhausted. However, the financial benefit of having this coverage should be weighed against the cost of plan (2013 national average was $30.00 per month) since the WCMSA funds cannot be used to pay for the plan itself.

For more detailed information about WCMSAs and supplemental coverage, visit www.Medicare.gov.

Settling a Workers’ Compensation Claim – Future Medicals and Medicare

Will Medicare cover my future medical expenses for my workers’ compensation injury if I settle my case? Yes, no, maybe…the answer to this question is always a tricky one. In fact, this is one of the most complex questions that will confront an injured worker at the time of settlement.

Most settlements are final. Once you agree, you may have created a binding contract that will have serious financial repercussions for you and your family. It’s best to be prepared ahead of time so you fully understand the potential impact of a settlement. Settlement agreements cannot be set aside except in very rare circumstances. Before settling your case, you should take a full accounting of your future medical expenses and your insurance coverage. In reviewing your medical needs, do not forget to account for over-the-counter medications. These costs add up quickly over time.

If you are already a Medicare beneficiary, it’s quite likely you will need to set aside a portion of your settlement for future medical expenses. Medicare may refuse to pay for medical coverage relating to your injuries unless you’ve allocated some of the settlement funds for future medicals. Determining how much to set-aside is another complicated question and usually an outside company is hired to help assist with this determination.

Furthermore, injured workers must also take into consideration the fact that there are certain medical expenses that Medicare may not cover. For example, when an injured worker needs someone to take care of them. Medicare will not pay for these services so the injured worker would be forced to pay if she failed to negotiate this amount prior to settlement. Also, even when Medicare does help foot the bill, the injured worker will still likely pay the coinsurance amount (typically 20%). In short, be careful and think about future medical expenses.

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.