Medical Drives Everything


The “claim-centric” approach to handling workers’ comp claims is misguided.

Hear me out.

You’re a parent of a sick child. Her pediatrician wants her to get ear tubes and an antibiotic. The insurance company’s claims rep denies the request, instead requesting an X-Ray and Tylenol, telling you to call back in a few days if that doesn’t work.

Of course, the claim rep thinks she’s doing the right thing and has decades of experience – but no medical training, no RN or any other designation.  You appeal to your daughter’s case manager, who agrees with the pediatrician.

And the claims rep rejects the case manager’s recommendation.

24 hours later, your baby daughter has a fever and is hoarse from screaming and you are at the local ER, about to lose your mind.

This is how almost every workers’ comp payer “manages” medical treatment.

Claims reps/adjusters/examiners with zero formal medical training decide what medical care your claimants get.

They approve opioids and spinal cord stimulators because they don’t want to hear from an attorney.

They deny surgeries because, well, because they don’t think they are necessary.

They refuse to pay for behavioral health because they don’t want to “own the psych.”

They “certify” 24 visits of PT because, well, because…

Medical drives claim outcomes. Medical drives claim costs.  Medical drives recovery and return to work. Medical drives litigation. Medical drives everything.

What does this mean for you?

Would you let a claims rep determine the care your baby or grandbaby gets?

Then why do you have claims reps determining the care your claimants receive?

By Joe Paduda

Courtesy of Managed Care Matters

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