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Effective October 1, 2005 PGIT will no longer be providing workers' compensation medical care through a managed care arrangement. Effective January 1, 1997, in workers' compensation cases all managed care was required to be provided through managed care arrangements. Many employers and insurers, however, dodged the law because there were no enforcement provisions. Effective October 1, 2001, the legislature amended the workers' compensation law to the effect that managed care was no longer mandatory.
The initial statutory amendment requiring managed care was supposed to lead to a decrease in medical costs. Managed care was thought to reduce medical costs through increased control of medical care through medical personnel and not attorneys, insurance carriers, adjusters, etc. Unfortunately, in most cases the savings never materialized.
Before the legislature implemented managed care they studied it through pilot programs. The study showed HMO type managed care arrangements resulted in significant cost savings. This type of program involved capitated contracts, that is, a contract where a fixed amount is paid in advance for future medical services.
The PPO program studied did not result in significant cost savings. Unfortunately, when managed care was implemented most programs provided in Florida came in the form of PPO arrangements, primarily because capitated programs were viewed as too risky for a litigated workers' compensation system. Accordingly, the cost savings never materialized. In affect, managed care employers and insurance carriers were paying for an extra level of administration without any corresponding savings on medical benefits provided. Because managed care did not result in any significant cost savings, it simply doesn’t make sense to continue.
In addition to the cost savings, under managed care it was typically easier for an employer or insurance provider to lose control of the workers' compensation claim. The claimant was allowed to pick his or her physicians from the managed care network. Often, the network included physicians no employer or insurance carrier would want to use. When a claim became litigated, you could bet the claimant would choose the aforementioned physicians. Accordingly, because employers and insurance carriers were not allowed to restrict a claimant’s choice within the managed care network, employers and insurance carriers could easily lose control of the medical portion of a claim.
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When managed care is not used, the employer or insurance carrier must provide reasonable and necessary medical care. Without a managed care arrangement the employer or insurance carrier can pick the claimant’s initial physician, and if the claimant wants a one time change, the employer or servicing agent must only provide a change to a different physician of the same specialty who is not professionally affiliated with the first physician. Simply put, we have a lot more control over medical care when we are only required to provide a choice of two unaffiliated physicians instead of providing our entire managed care list.
In addition to cost and control issues, changes to Section 440.134(6)(c)9, FS, effective October 1, 2003, require an employer who provides medical care through a managed care arrangement to pay for the claimant’s independent medical examination (IME). If medical care is not provided through a managed care arrangement the claimant must pay for his own IME. An employer or insurance carrier who provides medical care through a managed care arrangement is actually making it easier for a claimant to fund litigation. As I am sure most are aware, the claimant’s IME physician typically provides medical evidence that leads to additional compensation and medical benefits.
On a final note, we need to be aware that employers or insurance carriers, if they don’t pay attention, can still lose control of the medical portion of a claim. Section 440.13(2 )(f), Florida Statutes (2003) requires a carrier to authorize an alternative physician within five days of receipt of the request. If the employer or carrier fails to provide a change of physician as requested by the employee, the employee may select a physician and such physician shall be considered authorized if the treatment being provided is compensable and medically necessary. If the employer or carrier doesn’t respond in five days, claimants and their attorneys will use this provision to select a physician of their choice. You can bet the chosen physicians will provide evidence used to support an increase in compensation benefits and an increase in medical treatment. Therefore, to reap the benefit of increased control when handling claims we must keep our “eye on the ball.” Printable Copy
George A. Helm, III Esquire is an employee of Preferred Governmental Claim Solutions. PELS is established as a service and a benefit to PGCS and their clients. PELS is a not-for-profit enterprise. |
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Going, Going, Gone