Complex Issues Faced by Multiple Jurisdictions

At the 2014 IAIABC Annual Conference in Austin, regulators are discussing a variety of complex issues they are currently grappling with. Among the issues discussed were:

Hospital Fee Schedules
In states that do not have hospital fee schedules, the standard for payment is usually “reasonable and customary” charges. The question becomes, how do you determine what is reasonable? Providers push for billed charges to be the standard, payers feel this is an unfair standard as it is significantly higher than what providers ultimately accept as payment.

Payers push for paid charges to be the standard, but the providers argument against this is that PPO contracts dictate much of this, and those contracts are based on volume. If someone doesn’t have a contract they should not get the benefit of that discount.

Benefits for Illegal Aliens
Almost all states extend benefits to illegal aliens as not doing so would be against public policy. However, there is a significant question about what benefits these workers should be entitled to. Some states feel that workers should not be entitled to benefits based on the permanent inability to return to work or wage loss, while in other states such benefits are allowed.

The concern is, some states are awarding these injured workers permanent-total disability benefits because they cannot be put through vocational rehabilitation and returned to work. Attorneys are arguing that total disability benefits should continue when a light -duty release is obtained because that person cannot legally return to work. States are trying to find a balance between protecting the illegal alien workers while at the same time not rewarding them additional benefits simply because of their inability to legally work in the United States.

UBER
The explosion of the ride-sharing service UBER is causing concern with regulators around the nation. The big concern on the workers’ compensation side is whether these drivers should be classified as employees of UBER or whether they are independent contractors. Owners of taxi companies argue that allowing these drivers to be classified as independent contractors creates an unfair competitive advantage. States are challenged with whether they can classify these drivers by Statute or whether this should be done by the courts interpreting the current Statutes.

Treatment Guidelines
Several states including Washington, Texas and Colorado have pushed out treatment guidelines for issues such as opioids and treatment for low back injuries. The medical community tends to resist implementation of such guidelines as they feel this impedes their ability to render appropriate medical care based on the specifics of the patient. Those that argue for treatment guidelines point to a large body of research on the effectiveness of certain treatment modalities and the dangers associated with opioids above certain dosage levels.

Large Deductible Policies
Regulators feel there is confusion on the differences between large deductible policies and self-insurance with many employers feeling these are interchangeable. In some states, the courts have found that employers under a large-deductible policy cannot have influence over the claims handling process so they cannot access adjuster file notes, etc. It was stressed that under deductible policies, the carrier is ultimately responsible for payment of the claims and compliance with the Statutes. If the carrier is unable to collect the deductible from the employer, the regulators do not have jurisdiction over the issue. The deductible agreement is outside the parameters of the insurance policy.

The IAIABC provides an avenue for regulators from around the country to discuss these common issues and potential solutions.

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