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Employers And Insurers Gain Control In Workers' Comp Disputes

Posted by Julian Alexander on November 24, 2015

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Among some of the reforms made to workers' compensation laws throughout the United States are changes that give employers and insurers a greater degree of control in WC cases. Specifically, employers and insurers often have more power to select providers and challenge decisions about medical treatment through the use of independent medical examiners (IMEs) and mandated treatment guidelines.

The intention of these reforms is to lower medical costs and improve medical outcomes. Whether these reforms achieve those goals is up for debate, and it's worth exploring their scope and potential impact.

Provider Selection: Employee or Employer?

In a number of states, employers or insurers can now select the providers who will provide treatment to an injured worker. For many, this is seen as an interference in a very personal decision for the employee. In particular, is that taking this choice away from employees takes away the one advocate they feel has only the worker's interest in mind.

According to research conducted by WCRI, claims costs were higher and return-to-work outcomes poorer when workers selected their providers, as opposed to the employer making the selection. Unfortunately, these workers reported higher rates of satisfaction with their overall care.

It found the scenario where a worker selects a provider with whom he or she has history to be less clear. There was some evidence that costs were higher if the employer selected the provider, but the WCRI didn't consider the evidence to be strong. It also found that outcomes in such cases were similar to those when the employer selected the provider. Apparently the worst outcomes resulted when employees selected a new provider.

The conclusion here may be to work with the employee when selecting a provider. Thus providers with experience in the relevant injuries are selected, but with the input of the employee, which may lead to improving the worker's sense of satisfaction with their care.

IMEs and Medical Guidelines

Where permitted, either the employer or the insurer (or even the worker) can request an IME to review a number of claim issues. An IME can make its own recommendation whether to deny a claim entirely, revise or refuse treatment options, or make conclusions as to a worker's medical condition. Generally, the IME is conducting the review through consultation to evidence-based medical treatment guidelines selected by the state.

The concern is that IMEs become the mechanism by which insurers can override the medical decisions of a worker's own provider. Lending credence to this concern, a study of California's independent medical review (IMR) program found that IMRs upheld 91 percent of the decisions in the physician-level utilization review opinion. In essence, the IMRs were mostly agreeing with the insurer.

Supporters of the IME process and use of medical treatment guidelines point to the fact that prior to this change, decisions on treatment disputes between insurers and workers were made by judges. Not only did the judges have no medical background, the result was inconsistent treatments made available to different workers.

While it's too early to know if evidence-based guidelines lead to better outcomes, either medical or claims, it's clear that letting a claim get to the point where one party requests an IME presents a challenge to the employer/employee relationship.

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