Eureka! I think I figured out how employers or at least my former employer, Adventist Health (that religious hospital/healthcare corporation), saves money on the treatment of my work-related injury – they pawn it off on my private insurance. I think it’s the Workers’ Compensation (WC) version of a patient dumping scheme.
Over the past several years, through the use of utilization review and the claims adjuster simply ignoring the pleas of my WC physician they, Adventist Health (that religious hospital/healthcare corporation), have managed to pawn of the cost of nearly a year and a half of medications and numerous labs and medical exams onto my private insurance. This is a version similar to the patient dumping that numerous hospitals in the Los Angeles area have been accused of doing. On 2014, Glendale Adventist Medical Center (my former employer and where I suffered my work-related injuries) paid out $700,000 in settlements from patient dumping claims stemming back several years.
So here’s how, I think the WC patient dumping scheme works. They simply stop providing care, hiding behind utilization review (UR), even though the injured worker hasn’t been returned to pre-injury condition and may still be living with debilitating pain. Or because the process of getting care takes so long the injured worker then suffers additional injury/sequelae from the initial injury and from the failure of the employer to address the work-related injury in a timely manner. Then if the patient is provided care or finds a way to pay for the care/medications the employer sees this as an “out” for them from providing additional care, and each time the injured worker finds a way to pay for care for their work-related injury the employer see this as a “savings” and the process continues with the employer using UR to continue to deny any care or medication requested until the injured worker learns that the only way they’ll receive much needed care for their work-related injury is pay for it out-of-pocket and/or with their private insurance.
I find it interesting that UR review will deny let’s say pain medication for a work-related injury being handled through WC, but your private physician and insurance will cover the same pain medication. How is it that the private insurance company that everyone rails against seems to believe that its medically necessary and acceptable, but your WC claims adjuster and their UR agent comes to a different conclusion?
I guess its because your private physician really believes in his/her Hippocratic Oath. Meanwhile the WC claims adjuster has no such oath and the UR agent is someone who will never see you, the injured worker, and maybe hasn’t seen a patient in years. He/she just scans “the literature” so he/she can find a way to deny or at least reduce the care the injured worker receives all in the name of saving a buck at the expense of the injured worker – sounds like a patient dumping scheme to me!
More to follow . . .