Tag Archives: Reimbursement

“Florida, We Have a Problem”

Tuesday, Judge David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, wrote a rather lengthy post about the differences between cost-shifting and case-shifting in workers’ comp.

Much of what the Judge wrote were subjects that I already discussed in a number of previous posts about cost-shifting and case-shifting, so I won’t go into it here. I am only focusing on the parts that relate to Florida workers’ comp. You can read the entire article yourselves.

But what caught my attention was what he said about Florida and what the Workers’ Compensation Research Institute (WCRI) reported in some of their studies on these issues.

As Judge Langham wrote this week, he wrote a post two years ago that asked the question “Why Does Surgery Cost Double in Workers’ Compensation?”

Judge Langham noted in that post that Florida employers have been documented paying almost double for shoulder or knee surgery that is paid for under workers’ compensation, compared to group health costs.

The implication of case-shifting in Florida, he says, could arguably be a doubling of cost.

He cited a WCRI report released earlier this year that suggests however that case-shifting is perhaps not as likely in Florida.

According to the report, Judge Langham continues, “as of July 2011, six states had workers’ comp medical fee schedules with rates within 15% of Medicare rates. They were California, Massachusetts, Florida, North Carolina, New York and Hawaii.”

However, Judge Langham pointed out that the WCRI concluded that case-shifting is more likely in states where the workers’ compensation fee schedule is 20% or more above the group health rates, and not in Florida.

Judge Langham stated that this analysis of workers’ compensation fee schedules does not appear to include analysis of the reimbursement rates for hospitals, and that It also seems contradictory to the assertions that Florida workers’ compensation costs for various surgeries have been documented as roughly double the group health rates (100% higher, not 15% higher).

Injured workers who missed work in the Florida workers’ compensation system could be compensated in 2016 at a rate as high as $862.51 per week, the “maximum compensation rate.”

So, if recovery from such a “soft-tissue” injury required ten weeks off-work, he wrote, the case-shifting to workers’ compensation might add another four to nine thousand dollars to the already doubled cost of surgical repair under workers’ compensation.

This could be directly borne by the employer if the employer is self-insured for workers’ compensation; or, if the employer has purchased workers’ compensation insurance, the effect on the employer would be indirect in the form of potentially increased premium costs for workers’ compensation following such events and payments, Judge Langham states.

According to WCRI, the Judge quotes, “policymakers have always focused on the impact (workers’ compensation) fee schedules have on access to care as well as utilization of services.

This has been a two-part analysis, he says:

First, fee schedules have to be sufficient such that physicians are willing to provide care in the workers’ compensation system; and second, the reimbursement cannot be too high, or perhaps overutilization is encouraged.

Lastly, Judge Langham points out that the disparity between costs has also been noted in discussions of “medical tourism.”

The last question he posits is this, “might medical decision makers direct care to more efficient providers, across town, across state lines?”

What about national borders?


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Nickel and Dimed: Hospital Edition

Last week while I was drinking Indio and Dos Equis, Anthony Cirillo, president of Fast Forward Consulting, which specializes in experience management and strategic marketing for healthcare facilities wrote an article in Hospital Impact entitled, “Much like airlines, hospitals nickel and dime patients”, in which he says that hospitals have learned from the airline industry how to nickel and dime patients by making up reimbursement cuts by creatively finding ways to charge extra and often hidden fees.

Mr. Cirillo cites two articles in The New York Times by Elizabeth Rosenthal. The first article, “After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know”, mentioned that a patient received a bill from an assistant surgeon he did not know was on his case. The bill was $117,000. The primary surgeon was reimbursed for $6,200, but the assistant surgeon billed for, and was reimbursed for the $117,000.

The second article, “As Insurers Try to Limit Costs, Providers Hit Patients With More Separate Fees”, discussed how providers are billing patients for separate fees such as a $1,400 emergency room fee, which the insurer paid , when a husband and wife went to a hospital for a scheduled induction of labor for their second child, and a $2,457 fee for “noncritical activation” of the trauma team in addition to the hospital’s $240 facility fee, after a woman drove her stepdaughter to an emergency room after a bicycle crash.

Cirillo said that patients do have options and choice when it comes to their healthcare. They can choose between local competitors, go cross-county, cross-state, out of state and out of country. Medical tourism continues to grow and with the increasing number of Joint Commission International accredited hospitals, employers are actively choosing to send people overseas.

This option, as I have been saying now for two years, should also apply to workers’ comp. Anyone who thinks that hospitals will not try to stick it to employers and comp carriers for their injured workers’ medical bills is sadly mistaken, fee schedule or no fee schedule.

Employers who are self-insured or who are in a state that allows them to opt-out of the statutory system, are vulnerable to this adding on of fees to the total hospital bill, on top of what the surgeon charges for the actual operation, much the same way patients in the two articles by Ms. Rosenthal were.

When the bill came from the hospital in which my father passed away in, the total bill was over $200,000. I looked through it to see if there were any charges that did not seem right, but could not find anything out of place. With his health insurance paying the majority of the bill, our portion was still over $900.

Cirillo also stated that as high-deductible plans become the norm, these fees impact consumers directly and then cause health premiums to rise in tandem. Sure, he states, there are legitimate fees typically not reimbursed, but then there are the wink and the nod fees that have become so commonplace that they fade into the background and people are numb to them just like the airline charges.

Some employers have high-deductible workers’ comp policies, and it would be incumbent on them and their brokers to explore alternatives to extra and added-on hospital bill fees, and as Mr. Cirillo said, medical tourism can be one such alternative.

Travel expense may be reimbursed under certain conditions

Just happened to come across the following blog post here on WordPress from a workers’ comp lawyer.

The lawyer, Karl Voigt, answered a question on another website about being reimbursed for travel expenses in the state of Pennsylvania.

His response is worth considering for the implementation of medical tourism into workers’ comp, for all other states, besides Pennsylvania.

“There is a compelling argument that the carrier should reimburse your costs. Until about 1992, workers’ compensation carriers would regularly have to reimburse Pennsylvania claimants for all travel expenses incurred treating their work injury. Unfortunately, following the issuance of an appellate case, Helen Mining Co. V. WCAB, 616 A.2d 759, the law changed. The courts can now only award travel expenses in cases where the requisite medical treatment is not available in your locale. If you can indeed prove that it was absolutely necessary to travel out-of-state for treatment, there is a good chance that your expenses should be reimbursed.”

If an employee, or his employer believes that it is necessary for the employee to get their surgery out of state, i.e., in another state or even another country, it may be argued that the work comp carrier would have to pay for it.

Yet, if the carrier went along with it in the first place, there would be no need to request reimbursement, as the surgery and travel expenses would be paid for. If the employer and the carrier determine that they can save money by having claimants go out of the country for medical care, then there would be no need for the courts to award travel expenses in the first place, thus freeing the claimant from the grip of the medical-legal system that workers’ comp law has created.