Experts Weigh in on Medical Marijuana RICO Cases, Healthcare Costs
national workers' compensation practice
lead, Sedgwick CMS, Long Beach, Calif.
Medical marijuana, technology, and the federal interplay into the workers' comp system are issues he believes will spur activity. Additionally, he'll be watching RICO-related cases in Michigan and Colorado.
"They challenged the workers' comp system," he says. "Those cases are continuing to make their way through the court system with the Cassens case significant because the U.S. Supreme Court touched it twice, and it may go back to the Supreme Court for a final determination."
In that case, several employees alleged their employer, a third-party administrator, and an independent medical examiner conspired to deny them benefits. A separate case out of Colorado also includes a RICO allegation.
"Our concern is that while workers' comp is the exclusive remedy, you have these cases outside of that and into the federal courts," he said.
Cases involving medical marijuana will also be worth watching this year, Brown says. As additional states pass laws addressing the issue, he says the workers' comp system will need to respond.
"States will have to deal with employees who test positive after they sustain an injury, depending on what their policy says," he says. "The other part is once the claim is underway and the physician says [medical marijuana] treatment is necessary, workers' comp is going to have to deal with that issue."
With Medicare reporting requirements implemented, Brown believes the Centers for Medicare and Medicaid Services will find opportunities to collect money. But he says that's probably not the only area where the federal government will seek reimbursement.
"What we're also starting to see is Medicaid. It wasn't part of the MMSEA reporting but now they're looking for the same collection efforts where there was a primary payer but they paid and are now saying 'we should not have paid. You owe us this money.' We're seeing that already in California," he says.
Finally, technology will likely play a bigger role in workers' comp, Brown says, especially in communicating with injured workers. "That may mean looking at opportunities for text messaging . . . using cell phones a lot more."
Denise Gillen-Algire, practice leader, Integrated Health & Productivity Management, Risk Navigation Group, Albuquerque.
There's a broader interest on medical inflation and the medical management of workers' comp claims, Gillen-Algire suggests. That's changed the focus of claims managers.
"Several years ago it was the indemnity piece," she said. "Because there's this shift in the medical cost of a claim, there is a lot of discussion about what's driving that."
That's caused insurance carriers and employers to pay closer attention to the medical portion of a claim. She sees less resistance to including medical management from the outset.
"Research has shown time and again this helps facilitate better claims outcomes," she says. "Insurers are saying, 'maybe I should get medical management involved. Maybe I should have a nurse involved now instead of waiting.'"
As Gillen-Algire sees it, the increased medical costs in workers' comp relate to overall health care costs throughout the nation. One of the key drivers is severity, and the cost of providing the units of care and the services, she says.
"If you look at, for example, a diagnosis 10 years ago, and the tests that would have been done and the tests done today -- there are additional services, tests and procedures to treat the same condition, and more services provided."
Another key factor is the age of the clients. "You've got more people accessing health care services at a greater degree based on the aging workforce," she says.
Gillen-Algire believes predictive modeling will become increasingly focused on medical severity. While the idea of predictive modeling is not new, using it to take a closer look at the medical piece of a claim is a developing trend.
Read more at the WorkersComp Forum homepage.
March 7, 2011
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