In the world of the workers compensation industry, many times the parties involved enter into a game of chess. The game has many of the traditional elements to include a battle to see who wins. There are many pieces involved in the game from the insurance company, medical provider and patient. The insurance company wants to win by saving claim reserve, cutting costs, increasing case closure, and increasing profits. The insurance company uses claims adjusters who then utilize other game pieces such as private investigators, defense lawyers, nurse medical managers and vocational case managers. The medical provider utilizes the treating physician, medical assistants, scheduling coordinators, pre-authorization specialists, billing/payment staff and practice administrators as their pieces in the game. The medical provider wants to win by treating the patient, assisting the patient in recovery from their injury, and getting paid for the services provided. The patient wants to win by recovering from their injury, getting back to work, and moving on with their life. Many times the patient utilizes an attorney who represents their interests and joins in the chess match.
With all these pieces in play, it is not uncommon for a battle to arise between the parties. The battle leads to a maze of confusion, delays, misinformation, and frustration. This maze can also contribute to even further complications. As a medical provider the goal is to understand the chess match, utilize its pieces, provide quality care and be reimbursed properly for services provided. It is not uncommon for insurance companies to want to control all aspects of the game thus allowing them to win. If insurance companies can deny treatment, question appropriate care, medically manage the patients claim, delay payment and reduce charges for care – they win.
The compensation rules are clear and simple. Unfortunately, due to all the various pieces, managing the game can be difficult and will require diligence and perseverance.
SOME RULES OF THE GAME
- The treating physician is in charge of treatment and no other party can medically manage treatment.
- It is the treating physician who determines treatment facility and course of care related to the injury.
- Medical providers do not need to be on an approved insurance company physician or vendor list.
- Case managers have no authority to approve or deny treatment.
- Virginia is not a fee schedule state.
- Medicare has nothing to do with workers compensation reimbursements.
- Insurance companies need medical providers to treat injured patients.
- Pre-authorization for treatment related to an injury is not required.
Medical providers must understand the rules of the match, the pieces involved, and the strategy needed to operate a successful practice that treats Virginia injured workers. By remaining diligent and informed, medical practices can better understand and address the challenges presented to them on a daily basis. Are you a pawn or a king?
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.
