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Welcome To InteliHealth WORKERS COMPENSATION
InteliHealth
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                                  Players
 
 
Insurance Carriers and State Workers Compensation Funds
The payors of workers’ compensation claims are the insurance carriers, the self-insured businesses (if allowed by law) and municipalities, and the state workers’ compensation funds. 
The structure of insurance carriers is comparable to those for health, auto, life, etc. insurance, except that they insure specifically for job-related injuries. In fact, most insurance carriers are involved in several vertical markets, including those mentioned above. 
Most states do not allow self-insured coverage for businesses, although it is a fairly common practice for municipalities. Self-insured businesses are not always required to follow the same guidelines as businesses insured by an external carrier, although there is state legislation pending to remedy this, thus making self-insured status quite attractive to larger businesses.
During the 1980’s, the cost of providing workers’ compensation coverage was so exorbitant in some states, specifically due to the structure of (or lack thereof) workers’ compensation systems, that many insurance carriers refused to provide coverage to businesses in those states. As such, states were forced to set up their own "insurance" systems, which became known as state workers’ compensation funds, run independently from the state government, and often with a temporary mandate (which eventually becomes permanent, even with reform measures in place). This has happened in both Texas and California, although there are others. 
Businesses pay premiums to these organizations (except in the case of the self-insured) based on fairly explicit risk standards (i.e., the likelihood of someone being injured on the job, and the likely severity of those injuries). In return, the insurance carriers pay the bills for a job-related injuries. This includes emergency room visits; primary care physician expenses, including doctor visits; diagnostic expenses, such as CAT scans, MRIs, x-rays, etc.; rehabilitation-related expenses, such as physical therapy or work-hardening programs; and any lump-sum compensation due the injured worker at the end of his/her claim process. There is, understandably, a significant financial interest by the insurance carriers to streamline and limit payments, which is where IME’s come into play.
Health Care Providers—Independent Practices and Networks 
of Providers
These players include the physicians, chiropractors, nurses and nurse consultants, physical therapists, occupational therapists, and any healthcare provider that is involved in the diagnosis, treatment or therapy of an injured worker or patient.
Healthcare providers are on the front line, intimately involved with patient care. A doctor is often the first person who will see a patient upon injury, stays involved during the treatment, and gets to know the patient. Doctors, as front-line providers, are thus in a unique position to gauge the veracity or malingering of pain or injuries, including a patient’s willingness to participate in treatment. 
Although much of this may be gleaned from reports and medical records, even more may be derived from a one-on-one visit between doctor and patient, including a doctor with whom a patient has never treated. For this reason, insurance carriers exploit this by using "independent" (non-treating) physicians to determine prognosis and expected length of recuperation, among other things.
Plaintiff/Workers’ Compensation Attorneys
Depending on to whom one speaks, workers’ compensation (plaintiff) attorneys are the bane of workers’ compensation systems (especially insurance carriers) and the cause of the cost overrun problems, or fierce patient advocates getting their clients their due. The truth is probably somewhere in between. 
In fairness to these players, it is their involvement (and the cost of their involvement) that has instigated some much-needed reform in work comp. Some states, notably Texas, have revamped or are in the process of reforming the workers’ compensation process so that there is less of a need for attorneys. Unlike states like Massachusetts, that pay attorneys’ fees independently of the workers’ compensation claim, Texas has so regulated the system (refusing to pay these fees and limiting the payout claim) and provided such patient-protectionist measures, that use of workers’ compensation attorneys is rare. California, on the other hand, paid out over $3.9 billion in 1992 for workers’ compensation-related attorney fees alone.
The trends of more recent reform, in part due to lobbying efforts, does not exclude the participation of attorneys to the same extent as Texas. In any case, plaintiff attorneys are likely to remain significant players in the workers’ compensation process. 
State Workers’ Compensation Commissions
There is no national standard for workers’ compensation, so workers’ compensation is regulated at the state level, except in the case of the Federal agencies, such as the United States Post Office or the Department of Defense, which maintain their own standards and regulations. 
Each state has set different standards according to local priorities, although they are frequently watching what the others are doing as means of determining best of practices. Although legislature approval is often necessary to set or change regulation, state workers’ compensation commissions (or boards) are actively involved in researching and recommending regulations and statues, educating actors involved in the process, disseminating information, and facilitating workers’ compensation claims by acting as a neutral party between patient and insurance carrier.
Industry Associations and Other Resources
Accessing information about workers’ compensation trends, regulations, costs, or processes can be a tedious and time-consuming processes. This is compounded by the different state-determined regulations, which means there is little consistency across the board, and by the fact that the insurance industry is closely held and does not publish actual numbers or strategic visions. Nevertheless, there are a number of resources from which information can be gleaned. These include federal bodies that set safety standards, such as OSHA, industry associations, and independent businesses that get paid to track such trends.
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