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CWCI Annual Meeting Focuses on Stability Following SB 863

  • State: California
  • Topic: Top
  • -  1118 views
  • - Average time spent on item: 39 minutes
  • - Popular with: Legal
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OAKLAND, Calif. — You could call it a victory lap for the authors of the latest chapter i…

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Rhonda Wofford Mar 16, 2018 a 8:03 am PDT

This all sounds hunky dory. Bravo, good for us, self-congratulations all around, for the good job that we are doing!

However, there are other trends that are occurring; which are not the subject of carrier-funded studies or measured metrics; because, they won't result in a savings opportunity for the carriers.

Because, along with the justifiable laudable goal of rooting out provider fraud; there also has been, the piecemeal impoverishment of honest injured workers and honest providers.

The administrative tools that have been implemented are purposely too broad in their scope; such that, they create effects beyond those positive anti-fraud benefits being touted in this article.

What isn't being said; is that, while UR/IMR and IBR are cost-controlling measures, they are also fraud-producing measures.

Because, UR/IMR introduce additional administrative steps, in determining the medical reasonableness and necessity, of a proposed medical treatment. it forces dishonest decisions onto the honest patient and honest provider.

The honest patient is forced to recognize that the treatment that they need for a work-related injury, might be slow, or difficult to obtain through the work comp system.

If that work-related medical care is more easily obtained through that injured worker's private insurance; then, it makes it more likely that the otherwise honest injured worker, will use their private insurance, for their work-related injury.

That would be a fraud on the private insurance committed by the otherwise honest injured worker, to the advantage of the workers' comp carrier.

Similarly, if an honest provider bills strictly according to the OMFS, but then, a wrongly-reduced payment was reduced less than the cost of IBR; then, that provider is less likely to ever be paid for that wrongful reduction in payment; because, they won't pursue IBR.

That provider is forced into the position of paying out good money to fight a carrier's wrongful reduction. And if they prevail at IBR, it is not certain that they will be paid back for both the wrongful reduction; and, the amount that they paid for IBR in the first place.

So similarly, this creates an increased likelihood of payment fraud that is perpetrated on the honest providers, to the benefit of the workers comp carriers.

Nobody is being fooled by this "gaslighting" propaganda.

Trust me, nobody is fooling the honest injured worker who can't get proper medical care.

Similarly, nobody is fooling the honest provider who is billing according to the OMFS; who is now, suddenly making substantially less money.

This is a systematic and incremental, transfer of wealth, away from the honest injured worker and honest provider, and into the bank accounts of the workers comp carriers.

For proof, one need only look at the profitability of work comp carriers; matched against, the dwindling bank accounts of honest providers, to know that the transfer is real and intentional.

But nobody wants to discuss this because they claim they are righteously fighting fraud.

However, the larger effect is the fraud being perpetrated on the huge number of honest injured workers and honest medical providers. That is where the real money is being saved.

That is why they need to falsely inflate the number of providers "suspended" for committing fraud; when more than half of the "fraudsters" on that list, had their licenses terminated for offenses have nothing to do with fraud.



Roberta Curry Mar 16, 2018 a 1:03 pm PDT

Well stated.

Charles Cleveland Mar 20, 2018 a 6:03 pm PDT

Well said. An injured worker just left my office to whom I had to explain that his surgery, durable medical equipment, medication, physical therapy all got denied by a doctors whose names are secret and never examined him for any of those requests. Cost containment is good for profit, not so much for people. I've been following the stories on these suspensions, completely a bunch of cooked up statistics to look like a job well done. Probably less than 10% of all providers listed have any connection to the workers compensation system.

J anon Mar 17, 2018 a 10:03 am PDT

CWCI is the worst thing to happen to the injured worker besides the injury. Swedlow and his gang are raping the system with fake studies and massive kickbacks from carriers through side consulting companies. The carriers (CWCI included) direct fraud investigation efforts using their control of the fraud committee at CDI and are able to basically guard the hen house. Then they set up a med food, dme, or translation service company, while telling everyone to look the other way at meetings such as the one in the article, and start billing. A $400 bottle of milk and curry powder pills gets denied by an examiner....no problem, mgmt approves payment to themselves when it goes to lien. Follow the money and see who gets paid. Until a brave bill review analyst or other such employee finds a way to document the fraud and take it to the feds CWCI (along with Zenith, SCIF and others) is an enemy of all workers in CA.

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