Workers Comp and private insurance

racergaldar · #1 (**permalink**) 08-24-2008, 08:58 PM

The one good thing about my slip & fall at work is that as an HR Professional, I'm gaining knowledge and experience in the WC process so that I can help our employees who may (none so far) who have to go through this arduous process.

Since my injury in Jan 08, I've done excessive research (more than most HR) about the WC's system and spent hours on the Calif WC website, researched the ACOEM Guidelines (WC uses to make UR decisions), studied physician's and third party requirements. Even after all this, its still difficult to understand all these requirements.

I debated whether going the WC way, and still unsure whether it was the right decision. Our employer's private insurance approves discography and ADR when medically necessary and thinking about how to get out of WC. I've been told by the adjuster if I send a letter relinquishing all claims I can do that, but then I still don't know if my private insurance will cover considering it was WC.

Has anyone been able to switch from WC to private insurance? what did you do and what are the issues?

sahuaro · #2 (**permalink**) 08-24-2008, 11:04 PM

You are very fortunate to have insurance that covers discograms and ADRs!

I don't have any knowledge of the issues around WC vs private insurance but I do have a bit of info which may or may not be relevant: there is something called subrogation in which a private insurance company can recoup payments from a third party. If this is relevant, you might want to consult with a lawyer before making any decisions.

dshobbies · #3 (**permalink**) 08-25-2008, 03:27 AM

Ditto Sahuaro. Private ins may deny coverage if liability belongs to another party, i.e. wc. You may sign away your rights and find you're left with nothing or they may work with you. Going the legal route will protect your interests especially with everyone more than willing to pass the buck.

Good luck. I understand this is a rocky road!

Maria · #4 (**permalink**) 08-25-2008, 10:31 AM

When first injuring spine it was work related. Had private insurance from work as well. Was seen in ER at work that a.m. (worked in neurosurgery nights at the time of injury). Filed it as work related injury and because I could get nothing done back in the 80's with regard to injury/work status I filed a WC lawsuit and ended up not with the job but with a small settlement, voc rehab in the form of payment for MSN program that I had already started, and future medical benefits.

I have always used the WC benefits except for some testing and usually been notified that I needed to inform the insurance company of another insurance such as WC if I had it.

The last time I used private insurance for some osteopathic treatment on my low back I was advised by BCBS of Ma. that my claim was being investigated and asked to provide more information. I ignored the inquiries hoping the insurance company would lose interest in pursuing this but the inquiries became stronger and since it was my husband's insurance he was notified that the forms being sent out MUST BE filled out and returned.

Because I was seen with regard to total spine treatment with adjustment and complained of migraines (reason to be seen/treatment) as well as low back pain I was able to state this was not related to my back injury but rather treatment overall for my spine that just happened to include my low back as part of the adjustment. A very lame explanation but I wrote it, I had to repeat it over the phone to an adjustor, and it seemed to fly.

WC is a pain to deal with although fortunately I had my discograms authorized without any problem as well as MRIs (diagnostics) my first two surgeries and my 3rd proposed surgery when two level ADR trial was authorized then offer withdrawn, and several years later the recommendation became 2 level hybrid surgery which was also authorized with some time.

I will admit however that most of everything that was authorized more easily for me was before UR was involved in so much decision rendering as well as use of ACOEM guidelines and evidence based medical decisions in WC.

Seems like quite a bit gets denied these days that used to be authorized more readily (such as my 3 ESIs/year).

Good luck and tread carefully with this decision.

racergaldar · #5 (**permalink**) 08-31-2008, 09:47 PM

Quote:

Originally Posted by Maria

When first injuring spine it was work related. Had private insurance from work as well. Was seen in ER at work that a.m. (worked in neurosurgery nights at the time of injury). Filed it as work related injury and because I could get nothing done back in the 80's with regard to injury/work status I filed a WC lawsuit and ended up not with the job but with a small settlement, voc rehab in the form of payment for MSN program that I had already started, and future medical benefits.

I have always used the WC benefits except for some testing and usually been notified that I needed to inform the insurance company of another insurance such as WC if I had it.

The last time I used private insurance for some osteopathic treatment on my low back I was advised by BCBS of Ma. that my claim was being investigated and asked to provide more information. I ignored the inquiries hoping the insurance company would lose interest in pursuing this but the inquiries became stronger and since it was my husband's insurance he was notified that the forms being sent out MUST BE filled out and returned.

Because I was seen with regard to total spine treatment with adjustment and complained of migraines (reason to be seen/treatment) as well as low back pain I was able to state this was not related to my back injury but rather treatment overall for my spine that just happened to include my low back as part of the adjustment. A very lame explanation but I wrote it, I had to repeat it over the phone to an adjustor, and it seemed to fly.

WC is a pain to deal with although fortunately I had my discograms authorized without any problem as well as MRIs (diagnostics) my first two surgeries and my 3rd proposed surgery when two level ADR trial was authorized then offer withdrawn, and several years later the recommendation became 2 level hybrid surgery which was also authorized with some time.

I will admit however that most of everything that was authorized more easily for me was before UR was involved in so much decision rendering as well as use of ACOEM guidelines and evidence based medical decisions in WC.

Seems like quite a bit gets denied these days that used to be authorized more readily (such as my 3 ESIs/year).

Good luck and tread carefully with this decision.

This is good to know. Especially because lately I've developed new pains in the foot and ankle. After some research, I learned that some foot/ankle pain can also be attributed to nerve damage. Initially, the pain was in the leg and lower back.

racergaldar · #6 (**permalink**) 08-31-2008, 09:56 PM

Quote:

Originally Posted by sahuaro

You are very fortunate to have insurance that covers discograms and ADRs!

I don't have any knowledge of the issues around WC vs private insurance but I do have a bit of info which may or may not be relevant: there is something called subrogation in which a private insurance company can recoup payments from a third party. If this is relevant, you might want to consult with a lawyer before making any decisions.

Recently I attended a WC Seminar and after the seminar spoke with one of the presenters. When I first had my injury, I was embarrassed to file as WC because I'm in HR. I talked to a couple of other HR Professionals and asked them what they did and one told me she used her private insurance. I thought about that, then thought about the question on the patient info form "Is the injury work-related?". I didn't want to lie and I was afraid that if I did, the insurance would come back to me and ask me for full payment. However, when I spoke with the lecturer (specialist in WC), he told me that if later private insurance found out, they would go over after the insurance carrier. I verified this with an attorney during a consultation.

sahuaro · #7 (**permalink**) 08-31-2008, 10:28 PM

I'm glad you checked this out. Actually, my original thought was that this might put you in a very good position--since your private insurance covers ADR, it might put pressure on WC to cover it, if it came to issues of subrogation.

Maria · #8 (**permalink**) 09-01-2008, 08:22 PM

Is this a situation where one is injured at work (no matter what dept you work in or job title) and one files the injury as work related intially or doesn't?

If originally filed as Work Related injury and one has private insurance so in essence if one is seen as a non industrial accident/injury would this not make it more difficult have the WC carrier approve/pay on something that was seen as non industrial or does it just not matter because one filed as a WC injury originally but chooses to utilize private insurance and the insurances can battle it all out in the aftermath?

In between the time I had my first surgery and 2nd and even after 2nd surgery I was attended by my employer's insurance. Only when I went for MRIs, Pain Management and later more surgery did I utilize the WC insurance. Now since 2000 I've utilized my WC insurance but it's getting increasingly difficult to get ESIs authorized even 3 x/year which was the norm for me and helped greatly.

I've thought about using private insurance but then again there's that thing about *is this a work related injury*. If I say yes then I'm told it has to be dealt with by my WC carrier and authorization has to be obtained first. Sometimes I will be seen with private insurance saying my something else hurts and I know it's related to my low back prob but I want to be seen w/o all the hassle.

I do have to wonder that if I'm seen as a non industrial patient for my low back and get an ESI ordered/done then would the WC insuranc *have to pay* just because I have future medical on my low back. The adjustors have always told me that if I utilize another insurance for my spine problem and it's not authorized by WC they do not have to pay.

The WC firm that took care of my case advised me that the private insurance didn't have to pay for non authorized care related to my work related injury. I have tried consulting with other WC attorneys and I've had a range of advice such as take the money and run (what's offered in closing out future med) and that the legislation is so vague right now that it's hard to tell what will happen...

Allan hooked me up with someone that answered a question for me really easily and freely. The guy was great. Of course I didn't ask him *that question* as I had a situation at that time that was hanging over me WC wise.

If you can use your PPO/private insurance and get your needs taken care of, do so esp. if WC will pay anyway if the other insurance doesn't or if you've just decided to go the non WC route.

Eddie G · #9 (**permalink**) 09-14-2008, 06:56 AM

WC has been a double edged sword for me. They approve things after ALOT of begging & waiting. The adjusters job is to deny deny deny until they wear us out. You have to be a patient patient but keep on them. I got approval for my Prodisc by having my companies medical director call the insurance adjuster. When my company sent me for examination, they gave me a choice of 3-4 doctors to see. I chose the one who was ADR friendly (Vaccaro in Philly) It's a game and you have to know how to play it. Its frustrating at times but you have to get past that. I wanted to keep my claim a WC claim for alot of reasons. One of which is that they pay for my meds which at face value cost 2000+ per month. The doctors & nurses at work are helpful. Without them on my team it would be much harder Im sure.
Im now trying to get them to cover a mental health professional. I've left 2 messages so far with no reply. Its a game they play. As long as I get the answering machine they don't have to deal with me and can continue to put me off (saving their ins. company money every day they delay) It's not easy dealing with a-holes when you're in pain but if I want these things I have to play their sick f@!#ing game.

racergaldar · #10 (**permalink**) 09-14-2008, 06:15 PM

I don't know about your state, but in CA on the WC site, there is a complaint form. I have the same issue with my adjuster and debating whether or not I would want to piss her off. Speaking for CA only, when dealing with the State WC, the labor codes state specific response times. I just sent my request for a QME certified mail. They have 15 days to respond, otherwise I can pick my own. Considering our state budget hasn't been signed, low staff, I'm almost betting they don't respond in time. Also, when requesting a QME, if you have an attorney, when I get the 3 names, the WC scratches one, if I had an attorney, they would scratch another name, leaving me with just one to pick. If I don't have an attorney, I get to pick from the 3.

Although, these are CA regulations, you may want to check your state's labor codes. If you're WC insurance is in an MPN, look for that chapter as well. Having an MPN is similiar to having an HMO/EPO/PPO network.

BTW: how did you get them to approve the discography? I'm appealing my denial right now (thus why requested QME) (State Qualified Medical Examiner).

dshobbies · #11 (**permalink**) 09-15-2008, 02:07 AM

Just to inject a little humor here. All this reminds me of a report my son did in high school about owning your own business. You naturally have to deal with the IRS and the FTB but then there's the EDD and the SBE, OSHA, and perhaps the CLB or the BAR and in L. A. the CBL and PPT all of which is attached to you TID... as well as yearly clearances for a lot of other governing organizations with a whole lot of initials.

BTW, he got an A.