Workers Compensation Insurance as a Third Party for Medicaid

Medicaid is an entitlement program, jointly funded at the state and federal levels, which provides healthcare--both medical and long-term custodial care--to the poorest population of the United States.  Not to be confused with Medicare, the federally funded program available to most U.S. citizens and permanent legal residents who are age 65 or older, eligibility for Medicaid is means-based, and the program has strict income eligibility requirements that vary from state to state.

However, Medicare and Medicaid are not mutually exclusive--it is possible to be on both of those programs at the same time.

It is not unusual for Medicaid recipients to have additional sources of coverage for health care services. Since federal law dictates that Medicaid is the “payer of last resort,” this means that if another insurer or program (a third party) has the legal responsibility for costs involving a Medicaid-eligible individual, that “third party” is normally required to pay all or part of the cost of the claim before Medicaid makes any payments. Workers compensation insurance is one such third party insurer.

The Expansion of Medicaid

In the past, it had been uncommon for workers’ compensation claimants to also be entitled to Medicaid. If you were employed, chances were that you had too much income to qualify. That changed with the Affordable Care Act of 2010. Obamacare, as it is often called, expanded Medicaid coverage and allowed more workers to qualify for the program. Today, all U.S. citizens and legal residents, including adults without dependent children and with income up to 133% of the published poverty threshold, qualify for coverage. 

Workers’ Compensation Insurance and Medicaid Recovery

When Medicaid has paid the costs of an employee's medical treatment that was due to an employment-related injury, the workers' compensation carrier may find itself in the position of reimbursing Medicaid. Even if the carrier is unaware of the employee's entitlement to Medicaid benefits, it may still be liable for payment of past or future medical bills.

In December of 2013, Congress passed The Bipartisan Budget Act of 2013 (“Budget Act”). The Budget Act included a Medicaid Secondary Payer provision, which gave state agencies the ability to recover costs from a beneficiary’s entire settlement, rather than only those settlement proceeds designated as compensation for medical expenses. The Medicaid Secondary Payer provision was initially set to be effective on October 1, 2014. However, on March 31, 2014, Congress passed a bill that delayed the effective date until October 1, 2016, giving Congress and the states two extra years to evaluate the impact of the Secondary Payer provision.

Consequently, it becomes particularly important for a workers comp insurance carrier to evaluate a number of considerations during the settlement stage of a claim. It is also important that claim management teams become proactive when dealing with Medicaid recovery issues:

• Stay updated on any changes in Medicaid Secondary Payer recovery
• Identify claims from those who are receiving Medicaid benefits at the time of the insurance claim or who could become beneficiaries in the future
• Keep all parties that are involved in your settlements informed of Medicaid recovery efforts
• Put all appropriate state agencies on notice of their intervention and recovery rights

There is considerable effort being made to protect Medicaid's interests--especially in cases where Medicaid has absorbed the costs of medical treatment for which another party is deemed responsible. And some states are already beginning to flex their enforcement and recovery muscles in anticipation of Medicaid Secondary Payer becoming effective in October of 2016.

Help With All Your Workers Compensation Insurance Needs

If you have questions about this constantly evolving issue or workers’ compensation insurance in general, or if you would like to consider changes to your worker's comp insurance coverage, then contact us at (800) 947-1270 or (610) 775-3848.

When one of your employees is injured on the job, it sets off a sequence of procedures that must be adhered to in order to protect your business. If a claim is filed--whether compensable or contested—it is imperative that you have the necessary documents on file. Documentation for workers compensation insurance becomes particularly crucial with contested claims, as these documents become the lynchpin for a solid defense.

Start Documenting Workers Comp Claims Immediately

Documentation begins as soon as the compensation claim is received. An early intervention process allows for a claims expert to properly document pertinent information associated with the accident while the critical details are still fresh in the minds of the injured employee and anyone else involved.

Early workers comp insurance documentation has another advantage: often, the employee is still working, which allows unrestricted access to the worker before representation. This can lead to evidence that would be harder to uncover once a lawyer is involved. 

Other reasons for early documentation include:

• The injured worker and witnesses might change their stories if given the time
• Physical evidence can change or disappear
• Opportunities for research may be lost
• Proof of fraud or malingering may be missed
• Independent medical opinions may be jeopardized
• Symptoms are often exaggerated after a lawyer enters the picture

In addition, late documentation can damage an employer’s credibility and will sometimes lead to additional claims including harassment and discrimination.

Be Thorough in Collecting Evidence for Workers Comp Insurance Claims

It is worth noting that documentation of non-industrial injuries, tardiness, warnings, write-ups, and other personnel actions help to show the injured employee in a different light prior to litigation. Employers should be vigilant about maintaining proper WC documentation in the employee’s personnel file. This can be helpful in constructing an accurate portrayal of the worker before and after the injury.

Other workers comp documents that must be on file include…

• A comprehensive statement of the facts of the accident
• Witness statements, taken as early as possible
• Medical evidence obtained prior to litigation identifying the injury and body part
• Past medical records that are pertinent to the claim
• Independent medical examinations
• Personal and physical background information on the claimant
• Past claim records
• Photos and videos of the accident site
• Information procured from private investigators
• Copies of training programs and the employee’s participation in them
• Reports from professional experts and technical advisers
• A record of all telephone discussions with anyone connected with the claim
• A log of all employees’ functions from an up-to-date job description of all positions, especially modified duties

Medical Evidence is Key to a Workers Compensation Insuance Claim

While not every insurance claim will require this level of documentation, claim technicians will need many or all of these documents in some difficult cases. Many factors can affect the outcome of these cases. Experts seem to agree, however, that nothing is more important than medical evidence, procured prior to litigation, which identifies the injury or body part with a fair description of symptoms. Witness statements are also important, but witnesses have unreliable memories and are prone to leading questions. These factors lead back to the importance of early documentation.

Documenting a worker’s compensation claim is complex and time-consuming. But it is worth the hard work if it becomes necessary to defend a claim. Courts appreciate when complete and well organized paperwork is presented at a hearing.

Obtaining the Right Workers Compensation Insurance

Click here to contact us or give us a call at (800) 947-1270 or (610) 775-3848 to learn more about worker’s compensation and all of your insurance options. We'll help you choose the right policy and ensure you get a great deal because as indepenent agents we're free to shop among many competing workers comp insurance providers. Call or click today to get started.

Workers' compensation insurance allows employees who are injured on the job to receive payments for medical expenses, lost wages, and other expenses as they heal. It is usually paid by an insurance policy that has been taken out by the employer. Workers' compensation is required by law in most states, and receiving payment for workplace injuries may be an employee’s legal right.

But not everyone plays fair. Dishonest employees, employers, and health care providers are using fraudulent tactics to take money they do not deserve.

Fake Workers Comp Injury Claims by Employees

Most employees are honest, but the lure of free money, combined with the opportunity to bring in even more money at a second job, can be tempting. While only a small number of employees scam this coverage for personal profit, the damage can be substantial. Here are some of the ways dishonest employees can cheat the system:

• Embellished injuries: A worker insists that a minor injury received on the job is much more serious and requires a longer time away from work.
• Hurt off the job: Workers get injured elsewhere, but claim that they were hurt at work.
• Faking an injury: Some workers simply invent injuries. Injuries such as muscle problems with the back and neck are hard to disprove and easier to get away with.
• Previous injury: A worker with an old injury that never quite healed will claim he just got hurt on the job.
• Malingering: Workers pretend they're still disabled, even though they've healed enough to return to work.

Workers Comp Premium Scams by Employers

Fake injury claims far outnumber premium scams, but most workers comp insurance premium scams are much larger. A worker's bogus injury claim normally costs $2,000-$50,000 total. Employers can illegally reduce the workers comp insurance premiums they owe, costing hundreds of thousands of dollars in unpaid premiums in one year. Some scams can last for several years, resulting in millions lost. These cons can be complex and are hard to discover. Here’s how they work:

• Hiding employees: The company reports fewer employees or a lower payroll than it actually has. The owner might also falsely claim that some of the workers are independent contractors and don't count toward workers’ comp premiums.
• Misclassifying employees: The dishonest employer tells the workers’ comp insurer that many employees work at safer jobs than they really do.
• Avoiding coverage: The business doesn't buy state-required workers’ comp insurance, leaving workers dangerously exposed if they're injured.

Health Care and Lawyer Scams

Sometimes medical clinics and lawyers will team up to cheat workers’ compensation insurance. These are often well-organized and can steal millions of dollars a year. Here are some of the most common scams:

• Inflated injuries: Clinics may overstate the seriousness of injuries to workers, and bill insurers for costly and worthless treatments or tests.
• Phantom injuries: Clinics may bill insurance for treatment of injuries that never happened.
• Bogus lawsuits: Disreputable lawyers working with crooked clinics encourage uninjured workers to seek useless treatment. The lawyers then may threaten to sue unless the insurance company settles the phony claim quickly.
• Kickbacks: Dishonest clinics and lawyers hire recruiters to bring workers into the scams. The recruiters receive illegal kickbacks for referring patients to the lawyers or clinics.
• Bogus clinics: Some clinics are fakes. There are no licensed doctors or useful medical equipment. The clinic is merely a staging ground for bogus workers’ comp claims.

Workers’ Comp Insurance Fraud IS a Big Deal!

Workers’ comp fraud is a large crime in America. Tens of billions of dollars in false claims and unpaid premiums are stolen every year. That makes it a very big deal! Insurers pass on higher premiums to businesses, while consumers pay higher prices for goods and services from businesses. Workers may have their pay reduced or their jobs eliminated, while those who remain employed may be at risk in businesses that illegally avoid buying insurance.

Call Us to Get the Right Workers Comp Insurance Policy for Your Business

No businee is exempt from this problem.

Click here to contact us or give us a call at (800) 947-1270 or (610)775-3848 to get the right workers’ compensation insurance for your business.

Today’s businesses are paying greater attention to their employees’ wellness. Some are even taking a more holistic approach in which “wellness” is being supplanted by “well-being.” Whether your business is providing employees with fitness programs, diets, and screenings or adding meditation and massages into the mix, your employees reap tangible benefits…and so do you.

A healthy employee is more productive, has less absenteeism, does higher quality work, and gets injured less often. Production and quality help a company to be profitable and competitive. Fewer injuries lower workers compensation rates.

Sounds great, right? Why doesn’t every employer do this for their employees?

Connecting Wellness Programs to Workers Comp Insurance

While all of these wellness initiatives play an important role in improving employee satisfaction--along with the company’s bottom line--it is worth noting that if an employee is injured during an activity that was encouraged by the employer, it may be compensable. That's where having the right level of workers compensation insurance can make a real difference.

An Injury at a Fitness Center

Recently, an employee of a New York business suffered a spinal cord injury while participating in an exercise class at a fitness center. His employer had made the center available for all employees during working hours. The employer had also offered to pay some of the employees’ cost of the center. A Workers’ Compensation Law Judge determined that the claimant’s injury arose out of and in the course of his employment, and ruled that the employee was entitled to compensation for his injury.

The New York Appellate Division agreed. The court reasoned that the employer encouraged the claimant to have a gym membership, and offered reimbursement to its employees for half of their center’s membership fees. The court also noted that the claimant’s position required him to develop contacts with clients, and the claimant stated that he advanced that objective by taking classes at the fitness center. Since the employer sponsored the fitness center activity in this manner, the claimant’s injuries were ruled to be compensable.

A Lunch-time Basketball Game

In Pennsylvania, a Commonwealth Court found that an employee, injured while playing basketball on his lunch hour, was entitled to workers’ comp insurance benefits. The Court found that the employer had encouraged employees to engage in physical activities to improve their health, relieve stress, and to give them a better mental attitude at work. The employer encouraged such activities with postings on a bulletin board and by allowing its employees to use company facilities, including their gymnasium. Based on these facts, the Court found that the claimant was furthering the business interests of his employer when he was injured.

The Implied Requirement and the Need for Workers Comp Insurance

The South Carolina Supreme Court recently ruled that a man who organized a voluntary kickball game for fellow employees and shattered his leg during the game must be covered under workers’ compensation. In its decision, the court cited the testimony of the man’s supervisor, who said that while attendance at the game was not mandatory, he would have been “surprised and shocked” if the employee had not attended after organizing the event.

The case turned on the court’s view that the man was “impliedly required” to attend the event because of his role in organizing it. The decision doesn’t necessarily apply to other employees who are injured at an event where employees are encouraged--but not required--to attend. It does suggest, however, that employers should be aware that encouraging attendance may be regarded as an implied requirement.

Getting the Right Level of Workers Compensation Insurance Protection

For most employers, the benefits of promoting workforce wellness far outweigh the potential liability. But if your company is considering a wellness initiative, or continuing an existing one, it would be wise to seek the advice of an attorney in order to develop initiatives that promote the goals of the program while minimizing the risk of legal exposure.

Also, click here to contact us or give us a call at (800) 947-1270 or (610) 775-3848 to ensure that you have the right level of worker's compensation insurance to properly protect both your business and your employees.

Businesses today face challenges in managing a workers compensation insurance program, and these challenges can seem daunting immediately after a job-related injury.

Supervisors must make decisions for which they are not trained. Complicated medical questionnaires and claims forms must be filled out, leading to late and inconsistent reporting. These delays can create an opportunity for injuries to be embellished and, therefore, to become more costly.

Once an injured employee enters the medical system, the cost of a claim will escalate. A pre-claim nurse triage program addresses these issues and can provide help for rising workers’ comp costs.

What is Workers Compensation Pre-Claim Nurse Triage?

Telephone triage consists of specially trained nurses who are available 24/7 to receive calls following a worksite accident. This is a pre-claim activity in which the injured employee and a supervisor speak with a nurse who, in turn, assesses the injury and determines medically appropriate treatment. All recommendations come from an evidence-based medical protocol that ensures objectivity and uniformity. If the injury is minor, the nurse will provide first aid instructions that are specific to the injury. More serious injuries are referred to an off-site care facility. All information is recorded at the time of the accident, and the nurse collects all of the necessary data for reporting.

Workers Comp Benefits to the Employer

• The nurse triage system is easy to use.
• Company supervisors are no longer responsible for making decisions on injuries.
• The process is handled in a timely manner, leaving less chance for an employee to exaggerate the injury.
• Workers with minor injuries avoid unnecessary and costly treatment.
• Employees return to work sooner.
• Detailed reports of the incident are completed by the nurse and sent to the company.
• Typically, the money saved from claims reduction is substantially greater than the cost of the triage service.

Workers Comp Benefits to the Employee

• Immediate access to a medical professional who is trained to assess injuries.
• Medical attention is given sooner, resulting in better health outcomes.
• Early medical attention alleviates fears and concerns.
• Medical information acquired by the triage nurse prepares the employee’s primary care physician to determine a course of treatment, if needed.
• The employee is given self-care advice and instructions.

Your Workers Compensation Insurance Program Can Gain a Competitive Advantage

Today, business owners must be proactive and address the risks they face in injury management. In the past, costly trips to the hospital emergency room or unnecessary visits to urgent care and clinics may have adversely affected your bottom line. Pre-claim nurse triage can eliminate many of these trips and make your workers’ compensation program more efficient.

Typically with the use of a nurse triage, half of all sprains, strains, contusions, and lacerations, which collectively comprise about 70% of total injuries, are never entered into the medical system. Instead, a triage nurse is able to direct appropriate first aid treatment, resulting in significant savings.

This valuable program is not only for Fortune 500 companies. Any company, regardless of size, can take advantage of 24/7 nurse triage. Businesses report an average return on investment of 6:1 after one year in the program. Overall, workers comp claims are reduced by 44%. Less time off from work means greater productivity from employees. Add to this the decreased probability of fraud and lawsuits from disgruntled workers, and you have savings that find their way to your bottom line and give you a competitive advantage.

We Can Help Create a Better Workers Comp Insurance Plan

Workplace injuries occur in the safest companies.

Call American Insuring Group at (800) 947-1270 or (610) 775-3848 or click here to contact us for help in creating a better workers compensation plan.