An Update on
Workers’ Compensation
by Garry S. Moore, MD
Will the last doctor still accepting
workers’ compensation
please raise his or her hand?
Over the past several years, workers’
compensation has been in turmoil. As
many of you may recall, several studies
came out in 2001 or so that said the
cost of a workers’ compensation case in
Texas was higher than a similar case in
most places around the country, and
that our patients were no more satisfied
than those in the less expensive
states. The solution initiated in HB 7 in
the 2005 Legislature was the formation
of networks and the imposition of
strict treatment guidelines. It has naturally
taken a few years to implement,
but now both of those strategies are
fully operational and enforced.
At this point probably many of you
have been contacted about joining a network.
There are supposedly 24 networks
that cover Bexar County; instead, I think
for practical purposes, there are really
only a few. The advantages of joining a
network are assumed to be a reliable
patient stream and fewer hassles. The
disadvantage is that you accept the networks’
fee schedule. This can be good;
for example, 68 percent of hand surgeons
get paid more than 126 percent of
Medicare, 42 percent of orthopedists get more than 126 percent, or, not so
good, only 15 percent of family practice
providers in networks are paid
more than 126 percent of Medicare (as
of Feb 2007). Out-of-network physicians
have been paid 125 percent of
Medicare, an amount that will be raised
in March 2008 to about 139 percent.
The amount paid depends on your
negotiating skills and the supply and
demand issues of your specialty.
In the fewer hassles category is treatment
guidelines. Just as a network can
have its own fee schedule, it also can
have its own treatment guideline. Out-of-network providers are required to
use ODG guidelines. A network, on
the other hand, can require its members
to use the ODG, ACOEM guidelines,
a different set altogether, or even
no guidelines at all.
The first “report card” for networks
came out in September. There were no
significant differences in care received,
in satisfaction, and probably not in
cost either. In time there will be additional
report cards and findings.
I tend to be cynical, but it generally
seems as if the carriers and
employers have one view and the
providers and patients have the
opposite view. Too often the carriers
and employers have asked the questions
and gotten the answers that
seemed to support their opinions.
Lesser known aspects of worker’s
compensation are impairment ratings
and “Designated Doctor Evaluations.”
In order to make official impairment
ratings, the Division of Worker’s
Compensation (DWC) of the Texas
Department of Insurance requires
providers to take a course and pass
a test. Then, using the AMA Guides
to the Evaluation of Permanent
Impairments, they assess how much a
worker has been “damaged” by a particular
injury.
As one can imagine, there are many
conflicts in the life of a workers’ comp
case. The DWC uses designated doctors
to help resolve those conflicts.
Designated doctors essentially work for
the DWC and are trusted to be impartial
and unbiased. To help keep them
that way, they are compensated fairly
well. Even those doing impairment ratings
are fairly well-paid. Despite the
pay, however, I am told it is hard to
find doctors to do these, and recruiters
are always looking for doctors. A cottage
industry has sprung up handling
all the scheduling and paperwork. As I
understand it, the doctors merely are
required to meet the patient, do a physical,
and sign the paperwork.
This is an ongoing issue of interest
to physicians, one that has become a
regular component in today’s
medical practices.
Garry S. Moore, MD
is board certified in
Occupational and
Aerospace medicine.
He is a past president
of the Texas College of
Occupational and
Environmental Medicine.
Dr. Moore serves as a valued member
of the Texas Air National Guard. He
is also an active member of the BCMS
Publications Committee and a frequent
contributor to San Antonio Medicine.
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