According to preliminary data recently compiled by Cambridge, Massachusetts-based Workers Compensation Research Institute (“WCRI”), states that have a high number of employees using capitated health plans may see an increase in medical expenses shifting to workers’ compensation insurance. A capitated health plan is typically used by a managed care organization, such as an HMO or ACO, in an effort to control costs. Under such a plan, a doctor is generally paid a fixed amount of money per patient enrolled, regardless of the number of treatment visits each patient schedules. When a physician signs a capitation contract, the medical provider agrees to provide a specific list of services to each assigned patient in exchange for the agreed-upon fee. In other types of health care plans, a doctor is normally paid on a fee-for-service basis.
Richard Victor, Executive Director of WCRI, stated workers’ compensation insurance pays medical providers for services rendered on top of the fees received from a capitated health plan. In addition, capitated plans do not provide coverage for workplace injuries. This means an employee who is enrolled in a capitated plan and suffers a workplace injury that does not qualify for workers’ compensation benefits may receive only those services contracted for under the health plan. Because of this, Victor believes such health care plans encourage a physician to seek out workers’ compensation insurance payments for hurt patients.
To put it simply, Victor stated doctors who contract with capitated health plans are provided with a financial incentive to diagnose an employee’s injury as work-related harm. For example, if a worker complains of back pain or a soft-tissue injury, it is typically up to his or her medical provider to determine whether the cause of the injury is job-related. Such a determination is often a judgment call on the part of a treating physician. Due to resulting financial incentives, many capitated health plan physicians may resolve any ambiguities in favor of the condition being caused by a workplace injury.
As more health plans adopt a capitated payment model, Victor believes the trend towards shifting medical costs onto state workers’ compensation systems will increase. He stated the likelihood was particularly high in places like Massachusetts where more than one-quarter of workers are already covered under such a health care plan. Despite this, Victor was reluctant to accuse most doctors of intentionally committing workers’ compensation fraud.
If you or someone you love was injured at work in Massachusetts, you should discuss your rights with a hardworking Boston workers’ compensation attorney. The knowledgeable lawyers at Kantrovitz & Associates, P.C. are here to help you recover the financial benefits you deserve based on the severity of your workplace accident harm. To speak with a dedicated workers’ compensation attorney today, call Kantrovitz & Associates, P.C. at 800-367-0871 or contact us through our website.
Providers tap capitated health plans and workers comp for payment, by Sheena Harrison, Business Insurance (free registration required)
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