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Rx Medication (California)

PostPosted: Mon Jun 04, 2012 5:56 am
by 50Cal20
On the Friday before the Memorial Day weekend I was at a major workers' compensation insurance company. While there I reminded the adjusters to make sure they approved all Rx medication before they left for the 3 day weekend so that their injured workers would have their medicine. Afterall, nobody wants to suffer for three days while they wait for their pain medication to be approved. Much to my surprise more than 60% of the adjusters laughed and said they weren't going to approve it until Tuesday. They were serious. In fact, a few adjusters actually said that they would make it a point NOT to approve medication before the holiday weekend. Wow!

Re: Rx Medication (California)

PostPosted: Mon Jun 04, 2012 7:16 pm
by chirple
That is horrible!!!

On the other hand, the IW should not wait until they have less than 3 day supply before ordering refills!

Re: Rx Medication (California)

PostPosted: Tue Jun 05, 2012 2:00 am
Heinous....but karma is a pain, literally - they too may have to suffer the same fate.

It is a benefit delivery system, so the legitimately injured workers suffer because the adjusters have no sense of humanity?

Any claims examiner making that comment should have been immediately fired for a willful failure to timely deliver benefits and general stupidity. They call that a pattern and practice violation. Hope they get caught.

Re: Rx Medication (California)

PostPosted: Tue Jun 05, 2012 12:30 pm
by stewshe
chirple and Ginger,

I agree 100%! One of the first things I was taught on my first day as a W/C Claims Examiner/Trainee was "comp" is a benefit delivery system. To the extent it successfully delivers benefits to those entitled, it succeeds. If it doesn't . . . it doesn't!

The problem is all too many adjusters, supervisors, managers and entire companies focus on the 1 - 2% of fraudulent claims and "fight fraud" by doing fraudulent things themselves, such as delaying or denying clearly legitimate claims or benefits, such as timely Rx refills.

I saw some data in the news section a couple of years or so ago comparing costs of delivering $1 in benefits to injured persons. EDD's administrative costs were 5 cents/$1 while the W/C insurance and self-insurance industry's cost was over $2!

Sorry folks, that's being "Penny wise, pound foolish!" If most claims people could stop themselves from being so paranoid they would deliver more benefits in a timely manner, instead of causing delays AND THEN PROVIDING THE SAME BENEFITS MOST OF THE TIME while increasing their own costs through multiple internal and external reviews and litigation! (I've seen an Rx for a cane after a total knee surgery sent to UR and denied because canes were ONLY authorized under ACOEM for ankle problems! Too bad the doc couldn't Rx some common sense!)

Instead of adopting a scorched earth, "Admit nothing, deny everything and accuse all," approach it is much more cost effective to simply pay what you clearly owe. That is, look for reasons to pay, rather than reasons to deny. People tend to find what they look for! Also, when handling claims, a little common sense would be a big cost-saver!

Simply put, "Workers' Comp Claims should not be treated the same as tort claims." As Judge "Mike" Tarr (deceased) put it, "If you pay what you owe, you don't lose. Don't play to win . . . play to NOT LOSE!" What he meant was if an adjuster doesn't pay what is owed, the the adjuster and the EE both lose, though penalties are much less costly now than they used to be.


Re: Rx Medication (California) (California)

PostPosted: Sun Jun 10, 2012 12:37 pm
by rosellavera
That is a horrible war story. I can't believe anyone would be so mean. Do they know what the consequences are if someone goes through withdrawals especially if the patient is over the age of 50? They can suffer seizures and maybe a stroke. To any injured worker reading this. If this ever happens to you please go immediately to the emergency room and explain the situation. The carrier will be mad as hell having to pay $$$$ for an emergency room visit that could have been avoided if the IW's meds were timely authorized. Wow! How can people be so nasty?

PS - I know that this is an old post, but I just read it for the first time today. :o