And Stay Out!!


Most of us know, at least anecdotally, that workers’ compensation carriers often end up paying more for medical care than if that identical care had been attributable to a non-comp injury. For instance, we know that it’s going to cost more to repair a work comp rotator cuff tear than had that tear occurred during a weekend softball game. An analysis of this situation has been provided by Workers Compensation Research Institute (WCRI) researchers Dr. Richard Victor and Dr. Olesya Fomenko.

In NCCI’s 2014 Issues Report the WCRI Major Findings include:

  • In many study states, workers’ compensation hospital outpatient payments for common surgical episodes were higher, often much higher, than those paid by group health. For example, in half of the study states, workers’ compensation paid at least $2,000 (43%) more for a common shoulder surgery.

  • The amount by which workers’ compensation payments exceeded group health payments (“the workers’ compensation premium”) was highest in study states with either no fee schedule or a charge-based fee schedule.

A number of reasons are given by healthcare providers for this significant difference. Most often mentioned is the “hassle factor” associated with comp patients. It’s hard to argue that one. Frequently these patients are more difficult, may become litigious and may offer little or no payment if the carrier ultimately decides that the injury wasn’t compensable after all.

Since you can’t write your own legislation or draft your own administrative regulations, I have a good suggestion. Make sure someone who understands medicine is on your side. Make sure your utilization review vendor is up to the task of aggressive UR. Keep people out of the hospital whenever possible and do surgery only when medically indicated.

All research tells us that unit pricing is not the major issue with comp medical; the major issue is the number of units. Keep yours to a minimum.

Call us. We can do better.

William Faris, JD
Chief Executive Officer

Posted in OMCA