Barry Thompson

Fact: Affordable Care Act-styled health plans impose a new advent of deductibles on many soon-to-be surprised patients. Providers are reacting in ways that impact workers' compensation.

As a premise, there is a palatable fear among providers who foresee problems collecting deductibles from newly stunned patients who never expected these costs on top of copays and 80/20 reimbursement. Ask anyone recently visiting their orthopedic surgeon or taking a child for an ear, nose and throat evaluation. They now need to have a checkbook or credit card ready at the window. Providers have no appetite to collect deductibles after the fact. Mind you, from a business perspective, these providers are often risking zero revenue if they let a deductible patient off the hook.

I have the privileged vantage point of overseeing up to 50 new WC claims per month from two long-term, nationwide employer clients. I am absolutely experiencing deductible avoidance manifest as a direct problem for WC in two ways:

1) Diagnostic providers who used to simply take a claim number from a patient now require written adjuster pre-approval of payment. Consider that radiology or other diagnostic services are often caught in the flux of early WC activity. Their evaluations are used to determine compensability. Pre ACA, the likelihood of group health as a backstop against denied WC was a comfort. Providers now want to avoid the inevitable patient-deductible-collection scenario. The written approval phenomenon is also on the rise in PT facilities.

This is a very serious problem for WC claims because it presents an urgent situation to which adjusters are not accustomed and therefore not inclined to respond quickly. When an employee shows up for an MRI the day after their injury only to be told it is not approved and are sent home, or likewise for a PT appointment, it destroys any semblance of employee care that my good clients have worked hard to establish. The employee’s next call may well be to an attorney. I personally have had to chase unwitting adjusters down for days to perform this approval. It is new territory not in their work rules.

2) Providers are very boldly and deliberately ascribing patients to WC. I am not referring to grey-area confused patients. One of my clients has nurses on site who triage and ascertain employee situations while impartially deciding with their employees that an issue might be personal. These employees do not insinuate work-relationship upon provider examination. In fact, these employees are not even visiting the WC providers since the issue is personal. Astoundingly, in three instances of surgical need in the last five months from three different jurisdictions the employee doctors conclude conditions as work related and document the cases as such. This problem only occurred once before in many prior years of memory with my client’s experience.

Quick Tip – Prepare Your Team to React

– Meet with your claims service team and ask them to establish a process for immediate written diagnostic, PT or other specialist approvals. Alternatively, if you can target local providers with this adverse blanket policy then join with the TPA to intervene with those providers and try to remove this rule for your employees.

– Be prepared for provider sabotage. If an employee’s doctor has insinuated an incorrect WC situation then file a WC claim with immediate denial and prepare evidence, such as an employee statement or other medical documentation. As a first resort, if possible, use existing evidence to change the rogue doctor’s opinion. Failing this, arrange a visit to a preferred WC provider or an IME, but be certain to set such visits up with enough information to adequately support the employee’s own assertion that the issue is not related.

In conclusion: The deductible-avoidance reaction is one of many predictable ACA shoes to drop. As more challenges become realized, I will keep you apprised from the front lines of WC!

Barry Thompson is president of Acuity Risk LLC. This column was reprinted with his permission from his blog on the ClaimAnswers.com website, Workers' Compensation Quick Tips.