Tag Archives: insurance

Drug Formularies, Part 1: The Rest of the Story

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A drug formulary is a term describing a list of drugs that are covered by an insurance plan. In workers’ compensation, formularies are touted as a way to reduce prescription costs and lead to more effective care. Formularies are particularly pushed as a solution for opioid use and abuse for injured employees.

The headline numbers about the reduction of prescription costs look eye popping. One group of pharmacy benefit managers, the companies that manage drug formularies, claimed a 9 percent reduction in prescription costs over the last year. Ohio, which has the largest state-run workers compensation fund in the country, claimed a 16 percent reduction in prescription costs in the first three years after they implemented a drug formulary. Ohio reported 15.7 million fewer doses of opioids in that time period and a 36 percent reduction in opioid costs.

The Rest of the Story about Drug Formularies

Florida workers’ compensation judge David Langham has asked “what is the rest of the story” about drug formularies. If drug formularies are so effective, then why have they only been adopted in a few states for workers’ compensation?

While drug formularies are a relatively recent development in workers’ compensation, they are well established in the larger world of health insurance. Drug formularies have long been criticized for increasing costs in health insurance plans by reducing prescription usage because costs are shifted to insureds, which forces insureds to seek more expensive care, because chronic conditions go untreated. Overall costs are increased. The costs are also shifted onto insureds who have to pick up the costs for more expensive procedures that could have been taken care of through medication. Cost shifting from the employer onto the employee, other forms of insurance and the government is already a serious problem in workers’ compensation. Drug formularies in workers’ compensation could exacerbate the issue of cost-shifting.

Do Drug Formularies add up?  Cost = Price * Utilization

When you study drug formularies for any amount of time, you run across the equation that drug costs equal price multiplied by utilization. Proponents of drug formularies tout that they can decrease both the utilization and the price of prescription drugs. Ohio has provided detailed information about the decrease in the utilization of certain drugs like opioids because of formularies. However, the decrease in the utilization in opioids cited by proponents of drug formularies coincides with an overall long-standing decrease in the frequency or number of workers’ compensation claims. Fewer overall claims mean less overall utilization, which could explain some of the cost decrease. A better measure of the effectiveness in drug formularies in controlling costs would be measured by looking at prescription cost per claim. So far, drug formulary proponents have been unable to show that data. Even if drug formulary proponents could show that data, there is still the issue of whether reductions in prescription drug costs lead to increases medical costs by forcing injured employees to seek more expensive care that could have been taken care of by prescriptions.

On the price end of the equation, drug formularies are thought to control costs by having pharmacy benefit managers negotiate bulk discounts on prescription drugs. But pharmacy benefit managers have come under fire with allegations that they actually increase drug prices or at the very least are powerless to stop the increases in drug prices. The issue of drug formularies, pharmacy benefit managers and drug prices is complicated and will be addressed in Part 2 of this series.

The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

This entry was posted in Workers' Compensation and tagged , , , , , , .

Medical Care Politics in Worker’s Compensation

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Today’s post comes from guest author Thomas Domer, from The Domer Law Firm in Milwaukee. He writes about some perceptions that people have about injured workers and filing a workers’ compensation claim.

Although various blog authors who have been posted this year have put a focus on employer fraud, society through the media has put a big focus on employee fraud. No one lives in a vacuum, and for as many loved ones who support an injured worker’s right to compensation, there are also those folks who don’t understand how the system works or think that injured workers should just keep their heads down, suffering in silence and not going up against their employers.

But the reality is that, as I have said before, it’s better to have a good life than a good case. And if employers always did what they were supposed to in support of workers who were injured at their places of business, then the workers’ compensation process would be a lot less complicated, and injured workers would be helped a lot quicker, possibly with better long-term results.

If you or a loved one is hurt, keep in mind that loyalty to an employer in not making waves may be misplaced – be sure to focus on what’s important in the long term: the health of the injured worker and the well-being of their loved ones.

The mythology surrounding employee fraud in worker’s compensation is pervasive. Many of my clients begin their conversations with me indicating the following: “I’m not one of those folks faking their worker’s compensation claim.”  The exaggerated media publicity concerning employee fraud has also resulted in outright worker intimidation regarding filing a claim. I had this conversation today with a prospective client.

Attorney: Why didn’t you report the incident?
Client: I didn’t want to have that on my record.  Nobody will hire me if I have a worker’s comp injury.
Attorney: Why didn’t you seek medical treatment?
Client: I do not have insurance.
Attorney: Can you obtain insurance under the Affordable Care Act?
Client: You mean Obamacare?  No way!

Fear of being stigmatized as a complainer, whiner, or simply a recipient of worker’s compensation benefits has prompted many legitimately injured workers from filing a worker’s compensation claim.

The adverse publicity concerning the Affordable Care Act (and its pejorative popular name “Obamacare”) results in many otherwise qualified workers from obtaining the health care they need, especially when denied by a worker’s compensation insurance carrier. 

The politics of medical care intrudes in the worker’s compensation arena daily.

The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

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Work Comp Approved My Medical Care; Why Am I Still Getting Billed?

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Sometimes insurance companies do the right thing in workers’ compensation claims but medical offices don’t. A prime example of this is overly aggressive billing for medical services.

Under Nebraska law, an employer may only charge a certain amount for medical care covered by workers’ compensation care. Most importantly, the injured worker should pay nothing for medical care if it is covered by workers’ compensation. In Nebraska, workers’ compensation generally pays doctors a higher rate than private insurance.

The problem is that sometimes clinics will try to collect the balance from injured workers under the assumption that workers’ compensation works like private health insurance. Injured workers who get their care paid for by workers’ comp aren’t subject to deductibles or co-pays.

Sometimes clinics just make stupid mistakes.  I recently had a client who was billed by a surgical office for the expense of the employer’s lawyer meeting with the surgeon. Today, I had a client who was being flat out doubled billed.

Even if you are getting your medical paid, it would make sense to speak with an experienced workers’ compensation attorney in a scenario when you are being overbilled for care related to workers’ compensation. The same also goes if a medical office is aggressively trying to collect an unpaid bill from you. A knowledgeable lawyer can fight an unjustified collections case and can also advise you about your workers’ compensation.

Oftentimes, financial problems related to workers’ compensation injuries stem from an employee not getting loss-of-income benefits while they are healing. I defended a collection action for a client who was forced to use his wife’s health insurance to pay medical bills for his workers’ compensation-related medical bills. Having the ability to successfully prosecute a workers’ compensation case can relieve those financial pressures in some circumstances.

The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

This entry was posted in Workers' Compensation and tagged , , , .

Is Insurance Still For Policyholders?

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Insurance began in the Middle Ages, and policies could be written for almost anything. Policies were taken out to protect risks of trade, against the death of a head of state, and for many other forms of speculation. There was almost no limit on what a policy could be written for. Additionally, there was no shared risk as these policies were taken out only by individuals.

In the early 18th century, mutual insurance was created. Instead of individuals essentially placing bets that would pay off if tragedy struck, these policies created communities of members who were concerned with offsetting risk with reward. The lack of tragedy led to the payout of dividends to the members. Gradually, governments forced the transition of insurance from legal gambling on misfortune to companies behaving more like public utilities. Mutual-insurance companies helped the betterment of society with innovations like workplace-safety measures.

Over the last four years Edmund Kelly, former CEO of Liberty Mutual, has pocketed over $200 million in compensation.

In 1911, the first workers’ compensation insurance was written in Massachusetts in the form of a state-subsidized mutual-insurance company. Like most mutual insurance, the aim was the mitigation of risk by providing incentives to reduce risk and demanding small sums from each participant that were then combined into large sums for the victims or beneficiaries of the policy.

In the mid-1990s, insurance companies began pushing for legislation to authorize them to place their assets into holding companies that could then sell stock. Critics believed the policyholders were being divested of their ownership in such an arrangement, but little true resistance was brought to bear. What has transpired as a result of this shift is that increasingly the profits from insurance companies were being captured by its executive leadership instead of being reflected as profits and returned to its policyholders as dividends.

As such, 200 years after mutual insurance was created, history reversed itself. No longer was insurance sold to people who had a stake in the assets and risks on which they bet. The community no longer bore the rewards of mutual insurance as company profits were put in the hands of the elite leadership and not distributed across policyholders. One can surmise that policyholders also lost more control over how claims were handled than was anticipated when mutual insurance was created. Policyholders also likely see little incentive to follow risk-averse practices as they receive no return benefit in the form of dividends as they used to. When profit is the only goal in business only the business itself and, more specifically, its executives truly gain. One indication of this is Edmund Kelly, former CEO of Liberty Mutual. Over the last four years he has pocketed over $200 million in compensation.

Source: The Atlantic

The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

This entry was posted in Unfair employment practices, Workers' Compensation and tagged , .

The 12 Things You Must Do If You are Hurt at Work

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Today’s post is by our colleague Paul J. McAndrew of Iowa. While almost all of his advice applies to both Iowa and Nebraska, in Nebraska, unlike Iowa, you can choose your doctor. In Iowa you must see a “Company Doctor.” Regardless of what state you are from, you should not hesitate to consult with a lawyer if you were hurt at work and have questions or concerns.

 

Not seeing a doctor chosen by your employer could negatively affect the validity of your work injury compensation claim.

Injured workers call me all the time asking me what they need to do to make sure they protect their legal rights.  If you are hurt on the job, whether it is due to an acute traumatic injury (like cutting yourself on a saw), cumulative-trauma injury (like carpal-tunnel syndrome) or some other job-related injury, there are several basic things you should do. If you do not do any of the things on the list below, you may lose your rights under Iowa’s workers’ compensation law.

Although there may be rare exceptions to this list,  following it will leave you reasonably secure that your rights are protected:

  1. Report the injury. By “injury,” I mean almost any condition including but not limited to (a) an acute traumatic injury, (b) a cumulative-trauma injury, or (c) a disease or a hearing loss. You should report the injury to your supervisor or company nurse (for clarity we’ll just call these people your Supervisor from here on out), making clear your injury was caused by work. Under Iowa law, you need to make the report within 90 days of the date of your injury.
  2. Make sure your Supervisor prepares a company accident report.  If your Supervisor won’t prepare the report, then you should write a letter stating the facts of your injury and give a copy of the letter to the Supervisor. Keep a record of when you gave the letter to your Supervior. If you can get him/her to sign a receipt for having received it, that’s even better.
  3. Get a copy of the accident report and keep it in a safe place. If you prepare a letter, keep a copy of it.
  4. If you are part of a collective bargaining unit you should (a) join the union if you are not already a member and (b) tell your steward that you were injured and that you reported your injury to your Supervisor.
  5. Keep notes of all significant contacts you have with anyone (including but not limited to supervisors, insurance company representatives and doctors) concerning your work injury.
  6. Under Iowa law you must and should get medical care through the doctor selected by your employer (we’ll call this person the Company Doctor). Don’t get frustrated if you are denied care. Keep demanding proper care through the Company Doctor. If you go to your own doctor, you can make it look like you believe your injury was not caused by work. Also, under Iowa law your employer may not be required to pay for care you get from a doctor you choose.
  7. Tell the Company Doctor clearly and in great detail how your work caused your injury. If you do not think that the Company Doctor is caring for you properly or has not taken careful notes on how your work caused your injury, then give the doctor a written statement of how your work caused you injury and keep a copy of that statement.
  8. Follow all medical directions. If you don’t, your employer may argue that you chose not to get proper care and purposely stayed sick so you did not have to go back to work.
  9. If the doctor recommends you not do certain things at work, get the doctor to write that down and get at least 2 copies, one for the Supervisor and one for you to carry at work.
  10. Make sure that the doctor sends all bills to your employer for payment.
  11. If your employer and/or insurance company denies your medical care or the Company Doctor does not provide effective care, you have a right to seek effective medical care.  You do this by first demanding the employer and/or insurance company provide effective care to you.  If you are denied, you then need to file an “Alternate Care Petition” seeking an order from the Iowa Workers’ Compensation Commissioner that you be provided the effective care.  You can get a copy of the Petition at: http://www.iowaworkforce.org/wc/forms/14-0011altcarefillable.pdf. You should consult a lawyer if you are denied proper and effective medical care for a work injury.
  12. If you miss work because of a work injury, your employer may have a right to a 3-day “waiting period” before starting to pay you money benefits.  If your employer does not start to pay you after 3 days have passed, you should demand payment. If you are denied payment of money benefits for time missed from work because of a work injury you should consult a lawyer. You have a right to be paid money benefits in a timely manner – which means on the same day each week.  If that does not happen, you may have a right to a “penalty” benefit payment equaling up to 150% of the money benefits owed and not timely paid.

 

 

Image: Maggie Smith / FreeDigitalPhotos.net

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The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

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What Workers’ Compensation Fraud Actually Looks Like

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Some company owners fund lavish lifestyles with the money they steal through fraud.

What does workers’ compensation fraud actually look like? It looks like big insurance skimming billions of dollars and wealthy businesses living lavishly on workers compensation funding. Fraud costs everyone involved in the workers compensation system. Unfortunately the insurance and business interests continually claim employee fraud is a major problem. In reality worker fraud is a very small problem, accounting for less than 5% of fraud costs. A recent PBS segment summarized this fact very well. Please take a moment to read this and get the facts.

My respected North Carolina colleague, Leonard Jernigan, has studied real fraud costs for several years. His recent article, Billions in Employer Fraud: Top Ten Cases of 2011 is a must read for everyone who cares or is interested in the workers compensation system. Check out items 2 and 3 from his list below to see the old adage “if you are going to steal, steal a lot” at work in the workers’ compensation system:

  1. Compensation Risk Managers commits $1 billion in fraud, forcing many small businesses to close.
    Compensation Risk Managers (CRM), a company that acted as trust administrator for small business in New York State who self-insured for workers’ compensation, was sued in 2009 for $400 million in a lawsuit for fraud. Continue reading
The offices of Rehm, Bennett & Moore, which also sponsors the Trucker Lawyers website, are located in Lincoln and Omaha, Nebraska. Five attorneys represent plaintiffs in workers’ compensation, personal injury, employment and Social Security disability claims. The firm’s lawyers have combined experience of more than 95 years of practice representing injured workers and truck drivers in Nebraska, Iowa and other states with Nebraska and Iowa jurisdiction. The lawyers regularly represent hurt truck drivers and often sue Crete Carrier Corporation, K&B Trucking, Werner Enterprises, UPS, and FedEx. Lawyers in the firm hold licenses in Nebraska and Iowa and are active in groups such as the College of Workers’ Compensation Lawyers, Workers' Injury Law & Advocacy Group (WILG), American Association for Justice (AAJ), the Nebraska Association of Trial Attorneys (NATA), and the American Board of Trial Advocates (ABOTA). We have the knowledge, experience and toughness to win rightful compensation for people who have been injured or mistreated.

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