Reversal of Medical Director’s Approval in Louisiana

We recently received a letter from an attorney colleague of ours in Louisiana, Wayne Fontana with Roedel Parsons Koch Blache Balhoff & McCollister, informing us he recently received a judgement out of District 07 which overturned a medical director’s decision approving a $40,000 knee surgery.  Of note, the trial judge “specifically determined that the knee surgery was not in accordance with the medical treatment schedule and thereby overturned the medical director’s approval.”  It has historically been very difficult, if not impossible, to overturn the opinions of medical directors in Louisiana.  This has resulted, in our opinion, in inflated costs of future medical care as unapproved and unnecessary care has to be accounted for at the settlement of a workers’ compensation claim.  Once improper decisions are rendered by a medical director, decisions are typically made to not approach a settlement due to the increased cost to do so. Hello legacy claim.

This reversal is noteworthy as it could open the door for an increased number of successful, and medically appropriate, appeals.  Mr. Fontana said to us via email, “The more people who know that this medical director should be challenged and that, with the right case, his rubber stamp approvals can be reversed, the better.”  To our Louisiana clients, it would be a good idea to review prior unfavorable decisions from medical directors and investigate whether or not you might have a case for a successful appeal.

To view the letter from Mr. Fontana, please click here.

Article Details Evolving Trends in Catastrophic Workers' Compensation Claims

We ran across an article by Insurance Business recently that details some evolving trends in catastrophic workers’ compensation cases.  We took a particular interest in this because while not all of the cases we assist in settling are catastrophic in nature, many of them are, and maintaining a keen understanding of the trends within the workers’ compensation industry helps us to better understand our client’s current approach to settling claims.  

 The article indicates the soft market experienced by the workers’ compensation industry over the last several years may be reversing.  There are a variety of factors that contribute to the current landscape of catastrophic workers’ compensation claims, including injury frequency, escalating costs of medical goods and services, and the advancement of modern medicine and procedures that prolong the life of injured workers.

 In our experience, these types of trends can elevate the status of a workers’ compensation claim from “standard” to “legacy” quick, fast, and in a hurry.  It simply becomes less and less advantageous to settle a claim when projecting the escalating costs of medical needs over one’s lifetime. It is imperative to get out ahead of these claims and implement mitigation strategies to help resolve them once and for all.  We are here to help bridge the settlement gap and assist our clients in tackling these difficult to settle cases in their entirety.

 Again, our thanks to Insurance Business for a very informative article that can be read by clicking here.

CMS Rings in the New Year with an Updated WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) wished us all a Happy New Year by releasing the latest version of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide on January 4, 2019. The noted updates are as follows:

·     To eliminate issues around Development Letter and Alert templates auto populating with individual Regional Office (RO) reviewer names and direct phone numbers, these will now display the generic “Workers’ Compensation Review Contractor (WCRC)” and the WCRC customer service number “(833) 295-3773” (Appendix 5). 

·     Per CMS’ request, certain references to memoranda on cms.gov have been removed. 

·     The CDC Life Table has been updated for 2015 (Section 10.3). 

·     Updates have been provided for spinal cord stimulators and Lyrica (Sections 9.4.5 and 9.4.6.2) 

While the above bullet points are specifically highlighted as updates, it is worth mentioning that there are several instances within the WCMSA Reference Guide where CMS highlights the fact that the submission of a Medicare Set-Aside (MSA) to CMS for approval is a voluntary process. However, the WCMSA Reference Guide goes on to indicate that receiving CMS approval of an MSA is “the only process that offers both Medicare beneficiaries and Workers’ Compensation entities finality, with respect to obligations for medical care required after settlement, award, or other payment occurs.”  While, the workers’ compensation settlement community continues to explore alternatives to CMS approval including Evidence Based Medicine (EBM) MSAs, and other non-submission programs, the goal of these approaches should always be to avoid shifting the burden of paying for post-settlement treatment to Medicare.  

To view the updated WCMSA Reference Guide in its entirety, please click here.