The Payment System
The most important difference in state workers’ compensation systems is who chooses the treating physician. In general, workers’ compensation costs are lower is states where the company chooses the medical care providers, and higher where the patient has the choice. Although it is tempting to infer sinister reasons for this, the difference is similar in personal medical care insurance. When the company chooses the providers, the workers’ compensation system tends to resemble managed care or health maintenance organizations (HMOs). A limited number of providers are used by the employer or its insurance company. These providers are generally chosen because they are convenient and cooperative. They may be asked to sign provider contracts to accept reduced fees. If the outcomes are not good, if the employees are not getting well and quickly returning to regular work, the provider will be dropped from the program.
If the employee chooses the physician, the system works more like indemnification insurance. There are no negotiated discounts to reduce the fee- for-service costs. The patients tend to “doctor shop” until they find a physician who agrees with their opinions. And the employee may be given more time off for rest and recovery. Most states have a system for excluding specific physicians from providing workers’ compensation care if they are clearly biased, but the situations are usually extreme. The independent medical examiner who did not find a single permanent injury in 20 years of exams, and the orthopedist who took the employee off all work for six months for a sprained finger are equally unacceptable to the state administrators. They are not exercising good medical judgment, they are selling paper.
Any physician who is providing care for a work-related injury should base the decisions about care on his or her best medical judgment. As with any other payment system, it is not legal or ethical to withhold necessary care because it may not be covered by the insurance. On the other hand, providing care that is not indicated or giving employees time off that is not justified borders on fraud. One practice must be avoided because it is fraud: employees may ask their personal physician to treat them for a work-related injury and bill the charges to their personal health insurance. Their motives may be as benign as preferring the doctor they know and trust. However, their motives may be more complicated. The employee may be dissatisfied with the amount of treatment or time off they can obtain through the workers’ compensation system. The company may have policies or incentives that encourage employees to say that a work injury is not work related. Or the employee may simply not understand that it is illegal to lie about whether an injury occurred at work.
Medical care providers should be very careful about treating work injuries as though they were personal. If the patient is already being treated when the physician learns that this may be work related, the physician should contact the employer immediately. Treating a workers’ compensation injury as personal just to be sure you get paid is clearly fraud against the health insurer and may be a specific crime under the state’s insurance laws.