In workers’ compensation cases, many parties try to get their fingers into the proverbial pie. Often this leads to confusion as to who has the power to order what, or who must follow directives from whom. In Virginia’s system, the roles typically played by the various parties may be summarized as follows:
The Insurance Company – Employers with 3 or more employees must carry workers compensation insurance. When an injury occurs on the job, the employer must notify its carrier of the incident and the fact that a claim will likely be forthcoming.
The carrier then assigns a claims adjuster to investigate the injury and determine if a compensable injury occurred. Once the injury is determined to be compensable, the adjuster is responsible for issuing payments for lost time, medical charges, medications and other related expenses. When the injured worker returns to work, the adjuster decides for the insurance company whether it will offer any further settlement of the employee’s claim.
A Preferred Provider Network (“PPO”) is not an insurance company, but merely a broker seeking to bridge the relationship between medical providers and workers’ compensation insurance companies. Typically the PPO will seek to secure the provider’s agreement to accept payments lower than the provider’s standard billing rates, in exchange for the promise of an increase in patient volume. In Virginia, the largest PPO networks are Aetna, Focus, Coventry, Corvel and Sedgwick CMS. Other networks include TRPN, VHN, and CoreCare.
Repricing Companies are contractors hired by insurance carriers to handle bill review, to determine applicability of PPO rate schedules, and in the absence of an applicable PPO agreement, to seek bill reductions based on various criteria developed by the insurance industry. It is important to understand that many of the practices the insurance industry tries to impose are not actually in accordance with what Virginia’s Workers’ Compensation Commission would permit. Prominent repricing companies include Gallagher Bassett, Fair Pay Solutions, Viant, and Fair Isaacs, among others.
Nurse Case Manager is an RN assigned by the carrier to oversee medical care. Nurse case managers generally come to medical appointments with a patient and are asked to get information from the treating physician relating to treatment, recovery and return to work. Nurse case managers are sometimes accused of trying to dictate medical care to the treating physician.
Vocational Case Manager – Is hired by the carrier and usually gets involved in a claim once the injured worker is released to gainful employment. Many times a ‘Voc” person is responsible for finding new employment for the injured worker if return to work with the same employer is not available.
Attorney – there are 2 types of attorneys who can become involved in the employee’s workers compensation claim. The first is the claimant’s attorney; this person represents the injured worker to insure that benefits are provided correctly. A claimant’s attorney may also represent an injured worker in a hearing if a dispute between the parties arises. The second attorney who may get involved is the defense attorney. A defense attorney represents the insurer for any disputes that arise. Additional attorneys may become involved in a pending case, for example, representing medical providers in cases where they are underpaid by the insurance companies.
The Virginia Workers’ Compensation Commission (VWCC) oversees the Virginia Workers’ Compensation Act’s implementation and administration, and has been given the authority by the Virginia legislature to decide party disputes through an administrative hearing process.
The materials on this website are meant for informational purposes only and nothing contained in this site is to be construed as legal advice. If you need legal advice, you should contact an attorney directly. Do not act upon the information on this site without seeking professional guidance. Information on this website about specific matters or success in previous cases is not meant to be a prediction or guarantee of similar results in any other case. Each case consists of factors and applicable law unique to that case and you should consult an attorney.
