[red1030]

Hi all...I have decided to start this new thread to initiate an opportunity for everyone to list what they believe are the major issues surrounding the WC system. I will start with just a few that I have noticed here on this board.

1. W/C IC's are slow in approving recommended healthcare treatment programs often resulting in other agravating injuries which the IW is forced to fight for.
2. W/C IC case managers are not advocates for their customers (IW), they are not fulfulling the true role of what a Case Manager is defined as. They do not manage the health care of the IW, they manage the funds of the IC.
3. An IW is forced to hire an attorney because the W/C IC does not correspond with the IW to explain all their rights.
4. Employers do not explain the W/C Benefits to their employees as part of their annual education programs.
5. When a IW is determined to have reached MMI by the WC IC doctor, the W/C IC drops the case without explaining long term benefits that are prescribed by the individual states. They force the IW to hire an attorney to assist them to take them to court to get what is rightfully their to begin with.
6. There does not appear to be a regulatory body that governs and oversees the functions of the W/C IC in each state. They are not audited and therefore are not concerned about the decisions they make until they are forced into court. (This is something that I feel needs a lot of research to understand better).

This is just a few. I am sure that their are many more. I am a little tired so I may not have written them well and may want to rewrite for better understanding tomorrow.

If you have additional concerns, please add them to this thread. After we have collected a number of concerns or issues, I would like for all of us to make a decision on the top five issues. From there we will organize a team of 4 - 5 people working on each of the five topics. These teams would research and try to find as much information as possible about their specific issue.

Any one who is interested in being on a team to do research on a topic, please identify yourself in this thread as well. We could use help from all of you. You are what this is all about. All of us on here have had some experience with the W/C IC that is difficult to understand how it can happen. We all have feelings from sadness, hurtfulness, anger, and many more. Through all these emotions, we have developed thoughts about what we think and how we feel about W/C. We know what has hurt us the most.

This is just the beginning of attempting to obtain a thorough understanding of what W/C IC has meant to you in your life. We all need to have a good understanding so that we all can begin to collect information to share to the American Public. They need to know this.

For instance, right now there is a lot on the television about animal fighting. Is this new? I have known about this activity since I was a child. Did I agree with it, no, but did I do anything about it? I didn't know how to do any thing about it. However, omeone did and now everyone is outraged. The American Public does not know that they are not protected by the W/C IC as they believe. They do not know the games W/C plays and how they treat the IW. They do not know if you get hurt at work and your W/C IC deny's you, your other health care insurance may not pay for the injury. They do not know that many people lose their homes or their cars and file bankruptsy just because the don't get the care in a timely manner so that they can go back to work. They do not know that if they get hurt at work, no one will stand up for them, their employer, co-worker, etc. They do not know that when you get hurt, you are in so much pain waiting for the treatment to be approved. And even during this period the IC may not approve the pain medication prescriptions. They do not know that you may get hurt so bad that your whole life is turned upside down, that you may have to apply for SSDI to survive while you are hurting and grieving the lost of life you had prior to the accident.

The American Public feels that they are protected when they are at work. They do not know that they are not. We have a responsibility to share our stories and to prevent this from happening to anyone else. Ok...off my soap box...

Just give me a few ideas of your issues, and if you are willing to participate in a team on a subject. After we collect the information we will plan from there. Any ideas that may be better on how to do this is very much welcome. I am in unknown land on this..so I need as much help as possible...Carol (red)

[Still in Limbo]

Very Good Start Red! I feel another issue that needs to be addressed is the ability of the Big I/C's to lobby our Legislators for reform, and to be able to throw Money at them to be able to get issues passed that benefits the Employer, thus raising the i/c Bottom Line. There is currently no Regulations to stop this Lobbying, and the Injured Worker is the one who loses in the end. There is also no system in place other than small Penalties when the i/c stops Meds. or Monetary Payments to the Injured Worker, or if in my case, I've been underpaid on my weekly TTD for Three Years, and even though they have agreed (Defense that is) I am being underpaid, no on in the system is in a Hurry to get me my back Monies, and the Judge is in no hurry to rule on the issue, even after both sides have rested. Who's losing out on all of this, ME I'm the one selling things I hold Dear to pay Bills! Just a couple more, and I'll probably think of others as time goes on! Thanks Again Red!!

[capricorn]

Thanks Red......I feel the WC IC has one set of rules and the IW has another. We must do everything in a timely manner and yet they do nothing but stall. If we lie in a depo we go to jail. It is the norm for the IC to have attorney's that lie and get co-workers, NCM's, IME's to lie for money and nothing is done about this. When a claim is denied and the IW uses their own insurance to obtain medical attention, hires an attorney I feel that once the medical results are in, it then has been proven the IW really is hurt and hsould not take years for a Judge to get involved and make a decision. I'm having computer problems out the wazoo so will end there. Can't think straight right now, BUT I'm sure I'll be back with more.


CAP

[dipweed23]

what we need to lobby for first and foremost, is equal protection, and a federal mandate that a person's health is of the upmost importance. The proper medical care should come first. Their should be a law that states
1) All workers are to be proteced by workers comp insurance, regardless of company size, state, or number of employees... the insurance payment should be considered a normal operating expence.
2) All injured workers, after fileing an injury report with their employer, shal be treated promptly.
3) If ongoing medical care, such as surgery, is needed, the injured worker shal be allowed to choose their own doctor, and NO medical benefit shal be denied.
4) if the w/c insurance believes fraud of the system has occured, it shal be up to the insurance company, once proper medical care has been provided, to prove this fraud. They may use a federally approved board of doctors, a doctor of their choosing, whois a specialist in the feild of the injury, but not affiliated with the insurance company. It should be the responsibility of the IC to sue the patient in their county of residence for any fraud that has suffiently been proven.
5) The work comp insurance is to act like a private HMO. Referals shal always be hounered, but services can be reviwed. Their will be a non response time limit of 14 days for procedural review. no response means FULL approval of submitted service.
6) if a specialist needs tests, the tests are to be performed, no matter of the cost.

Something along these lines.

We need a federal law that is designed to regulate the industry, and protect the injured worker. It shal remain up to the states to further regulate the work comp, but it can not interfier with the injured workers bill of rights!

Once arm is better enough, and i have my microphone I will work on something to see if you all like it. then one of our lawyer friends here can change words so they sound more latin, and other mumbojumbo that congress would accept.

[red1030]

Hi guys...great start. I have copied your responses and will try to put it all together with some thoughts I had while reading them. Remember that i am just acting as a team leader here and in no way am the person who should or not decided what is or is not important or the decision maker on topics. I am going to point out a couple of things that I thought about as I read your isses, like some of us are saying the same thing using different words...etc. Any way I have copied and plan to work on it today. today is my husband's birthday so all the kids except my oldest who is in Oregon is coming for a pool party. I have some things to do to get ready for it.. thanks so much. We are on a roll...RED

[Tuffy]

I don't know about other IW but as for myself, I would like to see the rules and etc of WC put in Laymans terms ,not all the legal jargon, so the every day IW knows just what they are reading and can understand, instead of having to research or hire an attorney to get through just the basics of WC, Am I making sense?

[dipweed23]

another thing to go along with federally mandayed work comp, is federal posting requirements.
Just like for minimum wage, discrimination, and FMLA! plain english please!

[red1030]

I have tried to color code this to make it easier on who said what.. lets see how it goes...

Still said:
[/color]To be addressed is the ability of the Big I/C's to lobby our Legislators for reform, and to be able to throw Money at them to be able to get issues passed that benefits the Employer, thus raising the i/c Bottom Line. There are currently no Regulations to stop this Lobbying, and the Injured Worker is the one who loses in the end.

Carol Says:
Are you saying that the IC cannot have a lobby group? For instance, everyone, every group and every set of issues has a right to have a lobby group. This is part of our constitutional rights. Or, is your issue here the fact that the IC has such a wealth of overhead capita that they are able to influence government decisions that negatively affect the American IW? If so, are you also questioning the fact that they have all this overhead? Why are insurance companies given a free reign to charge what they want and to deny what they want?

Still said:
[/color][/font]There is also no system in place other than small Penalties when the i/c stops Meds. or Monetary Payments to the Injured Worker, or if in my case, I've been underpaid on my weekly TTD for Three Years, and even though they have agreed (Defense that is) I am being underpaid, no one in the system is in a Hurry to get me my back Monies, and the Judge is in no hurry to rule on the issue, even after both sides have rested.

Carol says:
[/color][/font]I believe that you are saying that there are no regulations that oversee the activities of the IC. This has a negative influence on the IW because there is no one to assure that the WC IC act in a legal, professional, and timely manner. Also, I hear you saying that there are no timelines in the laws that create penalties for the IC if they do not pay and pay correctly in a timely manner. For instance, if we (the little person) are late on an electric bill, the electric company has the right to turn off its services. The IW on the other hand, has no law to support timely action and the IC has no laws that create penalties on the IC when they are in default.

Cap Said:
[/font][/color]We must do everything in a timely manner and yet they do nothing but stall. If we lie in a depo we go to jail. It is the norm for the IC to have attorney's that lie and get co-workers, NCM's, IME's to lie for money and nothing is done about this.

Carol Says:
[/font][/color]Cap..You have hit on something that I feel is very important and yet very difficult to put into an issue. The issue is not the fact that they lie, it is how to prove they lie as a little person in a big system. Or are you saying that there must be more regulations that monitor their activity and decisions to protect the IW?

Cap Said:
[/font][/color]When a claim is denied and the IW uses their own insurance to obtain medical attention, hires an attorney I feel that once the medical results are in, it then has been proven the IW really is hurt and should not take years for a Judge to get involved and make a decision

Carol Says:
[/font][/color]What I hear you saying here is about timeliness of decisions and processing of claims. Do you feel that any claim should be denied? Or do you feel that it is the ownership of the IC to pay the claim so that the IW continues to obtain healthcare and then it would the IC to take the person to court if they feel there has been fraud. If so then this issues would be nil and void. Does this make sense or am I going down the wrong path here?

dipweed said:
[/color][/font]All workers are to be protected by workers comp insurance, regardless of company size, state, or number of employees... the insurance payment should be considered a normal operating experience.

Carol says:
[/font][/color]Most states do not mandate the employer to obtain WC Insurance if they have less than 50 employees. There is a reason for this. The reason is to encourage the small business man to operate. Most of these are mom and pop shops that do not carry WC Insurance because it is not affordable. This could be similar to a family who can’t afford to buy healthcare insurance because they make $10 an hour versus $40. If a family has to choose between food and healthcare, food will win out every time. If a small business man has to choose between making enough to pay all his employees versus paying for WC insurance then the salary comes first. This all comes down to dollars and cents.
I do believe that this is an issue, but not an employer issue, so how would we word this issue to assure that we are focused on the correct and obtainable solution. I don’t believe that our goal is to hurt the little business man. They are the back bone of American.

dipweed said:
[/font]All injured workers, after filing an injury report with their employer, shall be treated promptly.

Carol says:
I believe that you are referring to the issue of timeliness as referred to by Still, Red, and Cap. So we are all on the same page where timeliness of service is concerned.

dipweed said:
If ongoing medical care, such as surgery, is needed, the injured worker shall be allowed to choose their own doctor, and NO medical benefit shall be denied.

Carol Says:
[/color][/font]Dipweed this is a deep subject. The history behind the emergence of the HMO’s was to decrease healthcare expenditures. This was to be accomplished through some regulation and competition about doctor charges. They have attempted to create a system where someone else other than the physician is naming the price for a service. So my question would be to you on this issue, are you saying that you want to put this back into the physician’s hand? If so this would leave the WC IC vulnerable? Or are you saying that the WC should have a network of doctors that gives the IW a choice between doctors similar to the HMO experience?
The last part of your statement states “that NO medical benefit shall be denied.” So what I hear you saying is that the ownership of fraud is on the IC to prove and that everyone should receive healthcare first and then IC should be the ones taking the IW to court if they suspect fraud, not the other way around as it is now.

dipweed said:
[/color][/font]If the w/c insurance believes fraud of the system has occurred, it shall be up to the insurance company, once proper medical care has been provided, to prove this fraud. They may use a federally approved board of doctors, a doctor of their choosing, who is a specialist in the field of the injury, but not affiliated with the insurance company. It should be the responsibility of the IC to sue the patient in their county of residence for any fraud that has sufficiently been proven.

Carol says:
[/font][/color]Again, what I hear you saying is that the ownership to prove fraud belongs to the IC and not the IW to prove that it is not fraud.

dipweed said:
[/color][/font]The work comp insurance is to act like a private HMO. Referrals shall always be honored, but services can be reviewed. There will be a non response time limit of 14 days for procedural review. No response means FULL approval of submitted service.
I believe that here you are referring to timeliness of care, and that all claims will be serviced unless the IC can prove that it is fraud through the court system.

depweed said:
If a specialist needs tests, the tests are to be performed, no matter of the cost.

[/font][/color]Carol Says:
[/color][/font]What I hear you saying here is that the physicians make all the decisions about who gets what test and there is no concern to control cost…I agree with this to a point, I just have seen too many test that were ordered that was just non sense… and instead of a physician taking the time to educate the patient or person which is not billable, he orders a costly test which is billable, but not really needed. Again someone is allowed to make decisions on how to spend someone else’s money without any guidelines of control.

As of now, we have several similar issues if I am reading this correctly. However, I need your responses to my questions to make sure that I understand the issue correctly. Also I wrote some “food for thought per say” but that does not mean that I am right. We must narrow and focus the issues so that is what I am trying to do. Please response today if possible for the ones I have reviewed your issues and others please keep the issues coming. My goal here is to focus on the REAL issue that can be attached. There are always things that we can’t even begin to address and yet maybe we can…so let’s continue to move forward. No one said this is going to be easy, but nothing worth something has ever been easy for me, I don’t know about you, but not for me. The outcome is what it is all about. The process of time, energy and work is a given…Red

[ksgirl]

When most people are first injured they have no idea what to do. They tell the supervisor, then they are sent to the Dr. That's about it. Most injured workers have no idea what the laws, rules, or processes are. Their company doesn't volunteer anything and in my case (KS) the state website doesn't tell you very much either. I'm not a stupid person, but the state website is not easy to understand at all.
Why can't there be someone that gets in touch with the injured worker and explains how things work once you are injured. When you are already scared, worrying and in pain it can be hard to find out what your rights are and what the process is.
Red,
Thank you for being so caring!

[Tuffy]

Red, I agree with KSgirl, there must be something that can be done to help out the IW in knowing the ins and outs of the system. In my case I knew very little untill I found this forum many months after my injury, How many other IWs are kept in the dark because they do not know the process and are in so mjch pain all they want to do is have the pain go away. I just learned today something else, That I may have had a case for the EEOC with ADA as I was terminated even after my Dr sent a letter to my employer requesting I not be terminated and retrained for another position. I could have fought this but now it is to late. How many other IW go through the same thing. How many other IWs are out there not knowing there rights or what to do next??????? Why do so many that come to this board have the same questions over and over again, what do I do.