Dealing with Unscrupulous Medical Providers in Workers’ Comp
Show Me the Money: The Core Truth of Workers’ Compensation
In the world of Worker’s Compensation, there is one absolute truth; and to quote from Jerry Maguire, “show me the money.” Those who have been reading my blog understand that it is my position that all appropriate care should be delivered to the injured employee. You as the claim file handler need to be an advocate for the injured employee. However, it is clear that there are several evolving tangents that each individual claim file handler must deal with when attempting to resolve the claim.
The Challenge of Unscrupulous Medical Providers
There is one component of our little sandbox that is particularly onerous—and that is the unscrupulous medical provider. There are those who believe that insurance companies have the deepest pockets, and they can abuse the system with billing practices, up-coding, reporting services while billing for same without providing those services, and any other number of untoward schemes.
The frontline in defense against those underhanded practices is the Workers’ Compensation claim file handlers. These claims professionals should recognize these scandalous practices by those providers wishing to inflate their wallets, as opposed to providing all care reasonably required to address the actual sequelae of the compensable event.
Recognizing Red Flags in Questionable Medical Practices
The first step is to recognize the “red flags” that indicate questionable medical practices. This would include:
- Excessive frequency of visits (Does that sprained ankle need to be evaluated every three days?).
- Requests for unnecessary testing when physical findings do not support the need.
- Overreliance on passive treatments, such as excessive physical therapy, modalities, or chiropractic adjustments.
- Unnecessary work restrictions that may encourage less-than-candid behavior from the injured individual.
When Pre-Existing Conditions Are Misrepresented
Not all of these less-than-upfront efforts are geared solely to making money. Sometimes, in an attempt to assist the injured individual, certain declarations are made that try to tie pre-existing pathology to the reported compensable event.
For example, reporting a macerated, complex tear of the medial meniscus as an acute tear when there are no markers of acute injury identified in diagnostic imaging is unfair to all system participants. Worker’s Compensation costs eventually reach all consumers through increased prices of goods and services.
Building a Defense: Use Your Entire Team
How do we address this deceitful presentation? Use your entire team—including Nurse Case Managers, Defense Counsel, Utilization Review companies, and cost containment experts.
A good first step is ensuring that all providers are fully licensed within your jurisdiction, in good standing with their state medical boards or professional agencies, and maintain an honest reputation. Checking your state medical board’s website for sanctions or disciplinary actions is an excellent practice.
Scrutinizing Billing and Treatment Practices
The next step is to scrutinize billing practices. Use all available services to ensure appropriateness and accuracy. Look for signs of:
- Overbilling or up-coding
- Simple procedures described as complex to justify higher charges
When reviewing treatment plans, refer to established parameters such as those reported in the Official Disability Guidelines®. Verify that treatments are supported by utilization review and clinically indicated—and that they are tied directly to the compensable injury.
Establishing Trusted Provider Networks
Where possible, develop a network of trusted providers or referral sources who can provide comprehensive, independent clinical assessments. These assessments help clarify best practices and ensure injured employees receive the care they truly need.
Reporting Fraudulent or Inappropriate Behavior
If you suspect fraudulent or inappropriate behavior, report those providers to your state Worker’s Compensation system for investigation. Removing unethical actors strengthens the system for everyone.
Protecting the Injured Worker
It is your professional responsibility to protect injured workers from deceptive providers. Some employees may not be informed or may simply trust anyone wearing a white lab coat. If you recognize questionable behavior in your files, act promptly to transfer the injured employee to a compliant, ethical provider.
The Skills Every Claim Adjuster Must Master
Dealing with unscrupulous medical providers requires a specific set of skills for every claim adjuster—vigilance, knowledge, and strategic action planning. By maintaining the highest ethical standards, you ensure that every injured employee receives the care they need, as quickly as possible, with the best possible outcome.
