Category: Workers Comp

Jan
6

Predictions for 2021 – Workers’ comp

Posted by Joe Paduda on Wednesday, January 6th, 2021 | Comments

Never has the crystal ball been cloudier.

A lack of visibility does not mean one shouldn’t think through what might be hidden within the clouds. To quote Dwight Eisenhower, “plans are useless, but planning is indispensable.” While what we think may happen may not, the process of working thru the implications is hugely valuable.

So, here we go.

  1.  Total premiums will stay low.
    As employment, payroll, and injury rates all remain under pressure, total premiums will remain significantly lower than we’d expect in a non-COVID, non-recession environment. We are also on the tail end of the opioid cost bubble, with actuarial projections still over-compensating for what was rampant overuse of opioids.
    Unemployment will persist at least thru the first half of 2021 – and likely the first three-quarters – helping to keep premiums lower. There are some predictions that employment will ramp up towards the end of the year; let’s hope so.
    Implications abound.
  2. Facility costs will spike.

    Hospitals are in dire financial straits, with 2021 bringing no respite from the cash crunch experienced by the entire industry when people avoided facilities, put off elective procedures, or weren’t able to get care due to facility restrictions.
    As desperate financial managers look high and low for any and all revenue sources, you can bet your house they’ll be focused on workers’ comp. Payers have:

    • few effective price or utilization controls;
    • an often-lackadaisical approach to cost management;
    • bill review programs and processes hopelessly outclassed by sophisticated revenue maximization technology; and
    • management that doesn’t know that it doesn’t know;

thus payers are going to see facility costs – already the largest part of medical spend – jump.

3. Consolidation
Seems I’ve been forecasting increased industry consolidation for years…it’s not a prediction but more acknowledgment of reality. Workers’ comp is a declining industry with shrinking claim counts and flat expenses – and that isn’t going to change.

COVID has accelerated the process dramatically; with claim counts down 15-20%, there are fewer claims to adjust, fewer services to medically manage, fewer bills to pay, fewer dollars to compete for.
Because there will be fewer revenue and premium dollars next year than this, more consolidation is inevitable.
I expect this to be most pronounced among medical management firms and TPAs, and the big to get bigger. Genex/Mitchell/Coventry, Sedgwick, Concentra are all likely consolidators. Not sure about Paradigm.

4.  Drugs will re-emerge as a significant problem
After several years of declines in opioid prescription volumes, it looks like things headed in the wrong direction last year.
Prior Auth requirements were relaxed, refills extended, and states loosened restrictions on prescribing. Add to that patients weren’t able to get to their PT visits and surgeries were postponed. The result – I expect we’ll see drug costs in 2020 flattened out, and opioid usage actually increased (We will know a lot more in mid-late March when I complete my Survey of Drug Management in WC).
That was last year; as COVID is returning with a vengeance, expect to see continued increases in 2021.

5. COVID claims aren’t going to be costly.

Despite all the caterwauling we heard back in 2020, COVID costs have been minimal. That will not change. Yes there will be long-haulers, but those will be very few indeed. Yes there will be more claims, but most will cost just a few thousand dollars.

Tomorrow – the next 5.

 

Jan
5

Last year’s predictions…how’d I do?

Posted by Joe Paduda on Tuesday, January 5th, 2021 | Comments

As tempting as it is to just ignore my predictions for workers’ comp in 2020 and blame mis-calls on COVID, that wouldn’t be right.

So, here’s how I did.

 1. The work comp insurance market will stay soft.

Yep. And it would’ve stayed marshmallow-y soft even if the damn virus hadn’t spawned.

2. Work comp medical trend will remain flat.

As the kids say, that’s a hard yes...in large part because lots of injured workers didn’t get all the care they should/could have. However, I’m basing this on spotty information…we will know a lot more later this spring. But, so far, medical costs are looking flat to lower.

3.  Facility costs will gain a lot more attention.

Well, not enough. While there was a kerfuffle about Florida’s abject failure to correct it’s blatant giveaway to facilities, this got lost in the shuffle.

4.  Consolidation in the work comp services industry will continue, with more of the big players merging/acquiring each other.

Yup. Concentra went on an acquisition tear, and Mitchell bought Coventry.  Expect more to come in 2021.

5. OneCall will be sold.

Nope. While discussions were held at various times with various parties, the gap between what potential buyers would pay and what owners KKR and GSO would accept was too broad.

6. California’s crooked docs will be outed.

No dammit.

With SB 537 signed into law, I thought we would know which docs were the bad actors  in 2020 – like the  PM&R doc in northern California who filed IMR requests resulting in 2,800 IMR letters and 4,441 Medical Decisions.

(while the law doesn’t require this outing to happen before 2024, I’d expected we’d know the names of the worst offenders in 2020.)

7.  More effective approaches to chronic pain and opioid abuse disorder are here – and will gain a lot of traction in 2020.

That’s a yes – despite COVID sucking all the air out of every room, more and more payers launched smarter/better/more patient centric approaches to OAD and chronic pain.  Carisk’s Pathways 2 Recovery gained significant traction… (Carisk is an HSA consulting client).

8.  Don’t expect any meaningful state legislation/regulatory changes.

Well, outside of doing everything possible to expand access to and use of tele-everything, and all that stuff about presumption, nothing happened. Now that I read that…it’s clear that a lot happened. So, that’s a no.

9. Benefit adequacy will gain some traction.

I admitted this was much more of a hope than an actual prediction…and it didn’t happen. I’ll blame this in part on COVID…but Double Dammit.

10. Conferences will continue to struggle.

Uh, a  huge yes. I know, the demise of the conference was largely driven by COVID, but hey – I took the hit on leg/reg changes and adequacy, so will take a yes where I can get it.

Oh, and one more.

Back in 2019 I wrote this…

A very big external event/issue/mess will affect the economy – and thus workers’ comp

So, I hereby invoke the “better late than never” scoring rule and take a half-a-yes for this prescient – but 60 days too late – prediction.

The net – I got 5 1/2 points.

Tomorrow – predictions for 2021.

 

Dec
23

COVID update pre-holidays

Posted by Joe Paduda on Wednesday, December 23rd, 2020 | Comments

First – stay careful and smart – this is NOT the time to take risks; hospitals in many states don’t have room in their ICUs or ERs. Drive carefully, mask up (see below for info on the most protective mask), and DO NOT hang out indoors with people outside your “pod”.

To that point..

“Excess” death counts are used to better understand the real impact of COVID. In California, the pandemic is not only leading to tight capacity in hospitals, it is correlated with a significantly higher death rate, especially among Blacks and Latinx people.

This isn’t surprising; people of color are:

  • less likely to have health insurance and
  • thus are in generally poorer health;
  • more likely to live in urban areas with denser populations;
  • have less access to testing; and
  • more likely to work in “essential” industries and in “essential” jobs that place them at higher risk.

This from an NYC physician:

As a physician in an urban pediatric ED, I have worked with families who fear losing their jobs and medical coverage or exposing their children because they cannot work from home; families who feel abandoned by their primary care clinicians after their offices closed down; and families with language barriers or limited internet access precluding their use of telemedicine services, which are not always covered by insurance.

Also notable – the group that had the highest increase in excess deaths was people under 24 years old.

It’s not just California. A national study of excess deaths among 25-44 year-olds showed just over a third were from COVID.

Workers’ comp claims

COVID-related claims in California hit an all-time high last month.

A quarter of all claims in November were COVID-related.

BUT…claims are down by almost 17% for the year.  One out of every six claims disappeared…

double But – only (!) one of every 10 projected claims didn’t happen. (claims counts are on a decades-long structural decline)

Other key metrics:

  • about 1/3rd of all COVID claims are denied
  • over half of all WC COVID claims are for people under 40
  • to date, one of every eight claims is COVID-related

CWCI has led the way in reporting, documentation, and accuracy in all things COVID claim related.

Insurance execs are concerned.

As well they should be. The fine folks at NCCI report that COVID is the top concern amongst the insurance execs they polled.

I still don’t get fears about  presumption (the number 2 concern). COVID claims are cheap, resolve relatively quickly, and rarely become cat claims. Yes a very small percentage of patients may become Long Haulers, but even then they don’t/won’t represent a lot of dollars.

Concern about rate adequacy is even more puzzling.  Rates have been too high for years, driven largely by declines in opioid-related costs and disability. While that may change w the uptick in opioids, to date we’ve seen nothing that indicates the long-running gravy train that is workers’ comp is headed off the tracks.

What does this mean for you?

Prevention is the best cure – the most protective cloth mask is a two-layer woven nylon version.

If you don’t have one, use your regular mask this way:

See you next year.

 

Dec
21

Florida’s hospitals win big. Employers and taxpayers lose big.

Posted by Joe Paduda on Monday, December 21st, 2020 | Comments

Defying statutory requirements, logic, common sense, good government, fairness, basic math and the facts, Florida’s workers comp regulators just hammered the state’s employers, taxpayers, and physicians.

This is NOT yesterday’s Three Member Panel meeting, altho it bears a striking resemblance…foregone conclusion after a lot of theatrics

In a regulatory process resembling a Soviet show trial, the Three Member Panel slammed through a reimbursement scheme that will raise costs for employers and taxpayers while making sure Florida’s docs are among the lowest paid in the nation.

Allow me to list a few of the TMP’s many errors.

  1. The TMP failed to comply with the law that established the TMP, which reads in part:
    “Paragraph 440.13(12)(d), F.S. further 4 states: In establishing the uniform schedule of maximum reimbursement allowances, the panel must consider: 1. The levels of reimbursement for similar treatment, care, and attendance made by other health care programs or third-party providers; [note that several organizations gave the TMP data comparing WC reimbursement to Medicare and others; the TMP ignored it] 2. The impact upon cost to employers for providing a level of reimbursement for treatment, care, and attendance which will ensure the availability of treatment, care, and attendance required by injured workers…”
    The TMP said the scheme would reduce facility costs by 23%, citing an NCCI analysis that indicated the revised hospital fees. HOWEVER, the comparison data used in the analysis was from 2019, when hospitals were able to game the system by over-charging work comp patients. After a court ruling some months ago, many payers started denying outlier payments – and that continues to this day. [edit after hearing more from NCCI]
    Thus, the comparison does NOT reflect the actual difference between current and future costs due to the TMP’s new reimbursement scheme.
  2. The TMP refused to even consider the impact of rampant price-gouging by facilities with high charges on employers and taxpayers. This is very well documented, yet somehow escaped the TMP’s consideration.
  3. An incredibly naive comment by one TMP member illustrated his total ignorance about medical costs in work comp. According to a piece authored by William Rabb in WorkCompCentral, “worker representative” Jason Robbins said that in his experience, since few workers end up in the hospital, it’s not a big deal. [Why read WCRI studies when you can just rely on your own “experience”?)
  4. The estimable Mr. Robbins also noted excess insurance protects the insurers from high costs. Of course, employers and taxpayers have to pay premiums to excess insurers, which are driven by facility costs, a reality that appears to have escaped Mr. Robbins.
  5. Then there’s the hospital lobbyist noting that the law doesn’t require reimbursement to be “reasonable”…looks like the TMP bought into HCA attorney Jennifer Hinson’s opinion on what the law says.  Attorney Hinson’s opinion is – to be kind – not supported by the actual law, which states:
    “The uniform schedule of maximum reimbursement allowances must be reasonable, must promote health care cost containment and efficiency with respect to the workers’ compensation health care delivery system…”[italics added]
  6. Even the employer “representative” on the TMP, one Tamela Perdue, also voted in favor of hospitals. Perdue is an attorney employed by Sunshine Health, a Florida health insurer owned by Centene.
    I’m a bit surprised Perdue is a) on the TMP and b) voted; there’s a potential conflict of interest here as her vote favoring hospitals could be seen as a favor to hospitals in Sunshine Health’s network.

Finally, there’s a wealth of research indicating Florida’s reimbursement of physicians is way too low.  Rather than take a stand on this, the TMP just said it wasn’t anything they could do anything about.

Leadership at its finest, no?

What does this mean for you?

This is a not-very-well-hidden tax on Florida employers and taxpayers.

[note – I asked the Dept of Workers’ Comp for comment; as of this time they did not respond]

Dec
17

The snow job

Posted by Joe Paduda on Thursday, December 17th, 2020 | Comments

Here in central New Hampshire the snow is piling up..so far we have somewhere around 2 1/2 feet with more to come.

The weather reminded me of a vendor assessment project I did a while back for a workers’ comp client concerned with ever-increasing medical management fees. The program featured a medical management program integrated with TPA services, with the marketing pitch touting the efficiencies gained from one-stop shopping, electronic interfaces, close coordination and the like.

I won’t get into the specifics or identify the vendor – for reasons that will become obvious in the following.

Here’s some of what we learned.

  • Medical management fees – bill review, case management, UR, PPO, “enhanced” bill review and the like accounted for more than 13% of medical costs – a percentage way over industry standards.
  • Fee schedule reductions were way lower than those delivered by other BR vendors, but “savings” from “enhanced BR” solutions such as nurse review, bill negotiation and the like were really really outstanding. Notably the vendor didn’t get paid extra for FS reductions, but made 26% of savings for “enhanced BR” reductions. 
  • The TPA/vendor LOVED assigning case managers to claims; pretty much every lost time claim had a nurse engaged, and more than a handful of med onlies. A deep dive revealed that the CMs were doing a lot of what claim adjuster was supposed to do – discussing and documenting return to work discussions, talking with the patient and providers, even handling tasks which seemed more like claim intake and investigation. Of course this freed up the adjuster to do other stuff, and increased revenues for the vendor because the claim fees were a flat rate, but CMs were billed hourly… 
  • Nickel-and-diming was rampant; extra charges for worksite posters and provider directories, fees for accessing the claims portal, charges for processing duplicate bills, billing for windshield time for field case managers, % of savings for their PBM program plus add on fees for pharmacist reviews and drug alerts, mandatory annual increases due to “inflation”…pretty much any way the vendor could tack on a service charge, they did.
  • TPA claim fees were very competitive, but med management fees were way out of whack – PPO and “enhance BR” fees were north of 26% of savings, CM fees above $120 an hour (and no this wasn’t a California/Alaska/Hawaii client)

While the pitch made sense, once you dug just a bit deeper it became obvious it was a complete snow job; the vendor’s complete and total focus was on driving revenues, at the expense of a trusting client.

What does this mean for you?

Brush that snow away so you can really see what’s underneath.

Dec
15

COVID – quick takes on the latest research

Posted by Joe Paduda on Tuesday, December 15th, 2020 | Comments

A solid study found that the US infection rate is likely way higher than the official reports. The brainiacs at The Economist estimate almost one in every five of us has had the disease.

Coincidentally, I was talking with a client yesterday about his bout with what sounded a lot like COVID. Turns out his wife had it as well.  This is just one of several stories I’ve heard from folks who got sick as far back as last December or January.

The Economist has a very well done COVID tracker that provides data on excess deaths during the pandemic era, as well as a description of potential reporting issues and causes.

Before you scoff, read the article; the evidence is compelling that the pandemic has led to many more deaths than expected.

A study examining hospital readmission rates for COVID patients found more than a quarter died or returned to the hospital after their initial discharge. This sounds pretty high, but it is actually lower than longer-term death and readmission rates for heart failure and pneumonia patients.

Thanks to WorkCompWire for the piece on CWCI’s report on claims for public self-insureds for the fiscal year ending June 30, 2020. Recall that COVID hit California in early March, so the reports’ findings reflect 8 months of a “normal” year and 4 pandemic months.  Top takeaways:

  • Claim counts dropped over 6%
  • Indemnity expenses zoomed up almost 17%.

My view – it is highly likely the pandemic drove increased disability duration as patients couldn’t access care, facilities postponed elective procedures, and newly-injured workers found it harder to get appointments.

You’ll likely hear much more in a few months if you Save the Date for CWCI’s Annual Conference – on Thursday, March 11, 2021 the brilliant minds and best-presenters-in-the-industry will once again inform and enlighten.  Details forthcoming…topics to include a discussion on how the industry reacted to COVID and the results of current research.

Sticking with workers’ comp, a Kimberly George/Mark Walls piece in National Underwriter noted TPA Sedgwick has handled:

45,000 COVID-19 workers’ compensation claims for their clients. 78% of those are closed with an average paid of $1050. 54% of the claims had no payments made.

That’s pretty consistent with findings from my firm’s June 25 survey of 35 payers and service providers (summary report download at no cost); from an interview back in June:

a lot of claims are filed with no payments…[a] respondent stated “96% of claims cost less than $3,500, but 4% are expensive.”

Finally, the news that Moderna’s vaccine will likely be approved for use this week is excellent news indeed. The company participated in Operation Warp Speed, the Trump Administration’s effort to jumpstart vaccine development by funneling $18 billion in taxpayer funds to organizations and companies working on vaccines.

One of the most positive signs is Moderna’s vaccine showed equal effectiveness among white and non-white subjects. As COVID has been particularly devastating in communities of color, this is critically important.

This from the NYTimes:

There was also no significant difference between its protection for men and women, or between healthy volunteers and those at risk of severe Covid-19 who had conditions like obesity and diabetes. For people 65 and older, the trial provided an estimated efficacy of 86.4 percent, lower than the overall estimate of 94.1 percent. But the apparent difference was not statistically significant.

So far, two potential differences between the vaccines have emerged from the F.D.A.’s reviews, but the findings may [emphasis added] reflect a shortage of data rather than genuine differences. The Pfizer-BioNTech trial showed that their vaccine started to protect against the coronavirus within about 10 days of the first dose. The trial of Moderna’s vaccine, by contrast, did not reveal such a striking effect after the first dose.

What does this mean for you?

Wear the mask and be very careful. This is  very far from over.

Dec
10

Florida’s solution to hospitals’ financial mess is…

Posted by Joe Paduda on Thursday, December 10th, 2020 | Comments

To hear hospital lobbyists talk, you’d think Florida’s taxpayers and employers should subsidize hospital losses by paying exorbitant amounts for hospital care.

Yesterday’s virtual meeting of the State’s Three Member Panel (TMP) featured several hospital lobbyists and officials waxing poetic over proposed changes to workers’ comp facility reimbursement, citing the changes’ “fairness”, describing the TMP’s proposal as a “win-win” and the proposed changes as “reasonable”.

Ha.

After Hoovering hundreds of millions out of taxpayers’ and employers’ wallets for years, some hospitals want to continue forcing those taxpayers and employers to pay rates that are often 8 to 12 times what Medicare pays.  They cited an NCCI analysis that purported to show big system savings.

Unfortunately the analysis itself appears to be a state secret as it hasn’t been shared…so no one except NCCI and the Three Member Panel know what data was used, what time period it covered, the methodology employed, or anything else. That’s unfair to NCCI and to every stakeholder, unwise politically, and unhelpful as parties who like the finding can’t cite specifics, and parties that don’t like it can dismiss it outright.

What these hospital advocates didn’t discuss was the basic unfairness of Florida’s work comp physician reimbursement. WCRI data indicates the State’s docs, PTs, OTs, chiros, and other clinicians get paid less than their colleagues in every other state in WCRI’s report. The changes proposed by the TMP would increase providers’ reimbursement by a whopping 0.9%.

As WorkCompCentral’s Will Rabb reported in an excellent summary of the call,  the TMP is somewhat limited by statute, a challenge noted several times by Ass’t Director, Dept of Workers’ Comp Andrew Sabolic. However, Mr Sabolic’s words to the effect that it isn’t possible to define or determine “reasonable” (a statutory criterion for determining reimbursement) are puzzling. I’d suggest an analogy might be helpful (wish I’d thought of this while testifying on the call yesterday…)

Think of it this way; you pull into a gas station – which doesn’t post gas prices – in your personal car, fill up, and only after you’re done do you find out what you have to pay.

If you pulled into an HCA station, you’re going to pay about 8 times what the driver in front of you who filled up their government-issue car pays.

Under the per-diem plus outlier scheme that is kind of/sort of in place today (although many payers are basing reimbursement on a Court ruling essentially eliminating outlier payments) HCA – and some other mostly for-profit hospitals and health systems – get paid 8+ times Medicare rates.  And that was based on data from 2016; I’d suggest that it is highly likely you are paying even more today.

By any “reasonable” definition that is wildly “unreasonable”.

(A detailed discussion of this is here and here is an excellent report by Johns Hopkins researchers on Florida facility costs (non-subscribers to HealthAffairs have to buy it, but the summary is free)

I won’t get into the bizarre multiplier scheme proposal; suffice it to say that it is unique, hasn’t been used in any other state, is not based at all on what it actually costs a hospital to deliver services, and is completely game-able; any hospital can increase their reimbursement by a factor of 5 just by increasing their charges.

I will note that many hospitals don’t wildly overcharge work comp payers; many – but not all – not for profit facilities get paid less than 3 times Medicare.

What does this mean for you?

How is this “reasonable”?

If you want more info on why some hospitals are supporting this scheme, see here.

The TMP will meet December 17 to discuss implementing the changes; you can register here.

Dec
9

Making tele-health work.

Posted by Joe Paduda on Wednesday, December 9th, 2020 | Comments

It’s easy to dismiss tele-health as unsuccessful – and far too many have done that. That view is simplistic, and wrong.

There are two closely-related considerations that will drive tele-health’s growth.

As with any new technology-driven service, tele-health 1.0 is deeply flawed as it is based on developers’ guesses about what will work. 

Developers got some things right, and a lot of things wrong. User access to technology, internet connection speed, privacy concerns, health literacy, language and translation needs, and basic human fears and communication needs all drive adoption and usefulness.  Too often we don’t think about Maria Gonzalez, the working single mother with two kids living in rural California. Everyone has a smart phone, fast and reliable internet, a high level of comfort with medical providers and excellent English skills…so…we don’t need to deeply and thoroughly think through the what-ifs.

We are learning a lot and quickly. Those who listen, seek to understand, experiment, and keep an open mind will succeed.

Second, I purposely use a hyphenated label as it encompasses all things tele-health. Diagnosis, rehab, follow-up visits, medication checks, remote surgical consults, behavioral health – all are included in “tele-health”.

And all are different, likely require somewhat different approaches, technological support, documentation capabilities, and patient experience considerations.

Recent research indicates there’s lots we can learn – and some are learning – about early use of tele-health.

There’s another factor, one which makes tele-health potentially more helpful than in-office visits.

Clinicians can view the patient’s home, worksite, environment, their kitchen, bathing facilities, and exercise equipment. They can observe their patient exercising, taking meds, measuring their blood pressure or oxygen levels. They can help care-givers learn how to change dressings, administer medications, lift and move the patient.

This is far better than sending the patient home with barely-readable instructions, perhaps written in uninterpretable language, expecting the patient will follow those instructions to the letter with no mistakes.

Tele-health will be one of the topics discussed by workers’ comp program managers in a webinar tomorrow at 1 pm eastern. Registration here is free, courtesy of MTIAmerica.

 

 

 

Dec
8

COVID and work comp: delays in treatment = delays in recovery

Posted by Joe Paduda on Tuesday, December 8th, 2020 | Comments

Almost 400,000 surgeries (of all types) were cancelled each week during the 12-week COVID peak this spring. 

In North America, almost 1.2 million orthopedic surgeries were cancelled – the vast majority in the US. Across all countries, the orthopedic cancellation rate was 82%, the highest percentage of any type of surgery.

Assuming a 20 per cent increase in baseline surgical volume, the researchers estimated:
it would take countries a median of 45 (range 43–48) weeks to clear the backlog of operations resulting from 12 weeks of disruption due to COVID…
While surgical procedure volumes undoubtedly increased this summer, news reports indicate elective procedures are once again being postponed in Massachusetts and many other states.
Implication – claim durations are going to increase as patients requiring surgery are back on the waiting list. 
Even after elective procedures return, many patients will face weeks of therapy before they recover and return to full functionality.
Which leads us to PT.
The good news comes from MedRisk, a physical medicine management firm. Their annual Industry Trends Report shows post-surgical PT ramped up quickly this summer – after the COVID peak. (MedRisk is a consulting client)
The company also opined that the delay can complicate recovery because patients become “de-conditioned” while waiting months for surgery, although the delay can be mitigated by “pre-conditioning” patients with pre-surgery PT.
What does this mean for you?
These times are different and require different approaches to ensure rapid and complete recovery. “Pre-conditioning” may help your patients come out of surgery in better shape and feeling stronger…yes it’s different, and new, and a bit uncertain – but these times demand flexibility and creative approaches. 
Dec
2

COVID and workers’ comp…where are we?

Posted by Joe Paduda on Wednesday, December 2nd, 2020 | Comments

It’s time to dig back into how and where COVID is affecting workers comp. As this is very much a state-specific situation, we first need to understand what’s happening around the country.

That’s difficult at best.

(if you just want key takeaways, scroll to the bottom)

For starters, it can be quite difficult for a worker to get coverage for COVID; in most cases a worker must:

  • have a positive PCR test or a COVID diagnosis by a physician, and
  • be an “essential worker”, and
  • work in a state with some level of presumption.

Tests were hard to come by – and many were inaccurate – back in the initial March – to – May wave. Presumption laws have been a moving target and are subject to interpretation, as is the determination of who is – and is not – an “essential worker”.

Okay, the data… 

States’ data below are NOT directly comparable; states report things differently and totals are from different time periods. For example, Florida’s data includes only lost time claims that have been accepted or denied. California, Hawai’i, and New York include all claims filed. Can’t tell much from PA’s data…

Remember, occupational disease is NOT handled the same as an occupational injury; in laymen’s terms, in most cases the burden of proof is on the patient to show COVID was contracted in the workplace and not at home.  This from Florida statute:

“occupational disease” shall be construed to mean only a disease which is due to causes and conditions which are characteristic of and peculiar to a particular trade, occupation, process, or employment, and to exclude all ordinary diseases of life to which the general public is exposed, unless the incidence of the disease is substantially higher in the particular trade, occupation, process, or employment than for the general public.

California

CWCI’s reporting of COVID and related data is timely, robust, and accessible. As of November 30 – 2 days ago – there were 56,854 claims reported. Almost 19,000 were among healthcare workers and 7,700 suffered by public safety and government employees.

note the light blue indicates projected total claims; dark blue indicates reported claims

A lot of claims incurred in November aren’t included in those figures as they aren’t officially reported yet. So, looking at projections for the period ending October 31, CWCI projects there will be a total of 58,136 COVID claims.

68.1% of claims that have been assessed have been accepted, a rate higher than in most other states.

Overall, claim counts are down 12.9% for the year; that’s a loss of one of every eight claims.

New York

Over 12,000 COVID-related claims were filed, as of October 8,  the vast majority still pending.  To date, about 8,000 of the claims filed are lost time, 184 are receiving indemnity payments and another 5,000 claimants received “voluntary” wage replacement payments from insurers/their employer.

Around 1,230 claims were initially denied…and again, about 3/4ths are still pending.

Hawai’i

On the other side of the country, only about 400 claims have been filed in Hawai’i through October. About half were initially denied, and most are still under consideration. Not surprisingly, a plurality (166) were from healthcare or social workers.

Florida

As of October 31, the Sunshine State has accepted or denied 23,000 COVID-related lost time (LT) claims filed, 13,000 have  been ruled compensable and the rest denied. Key findings include:

  • COVID claims account for 31% of all LT claims filed but only 8% of payments
  • Paid amounts to date show 94.6% of COVID claims cost <$5,000
  • 6 claims of the 23.452 have resulted in benefit payments over $500,000; the average is $800,000
  • the average benefit paid for all closed COVID LT claims is $1,092.

Pennsylvania

PA had 9,510 COVID-related claims as of 11/29/2020;  no indication if those are filed, accepted, include all claims or not.

Texas

Our friends on the border reported 25,571 claims as of September 27, 2020 – the vast majority have not been accepted or are still being adjudicated. Similar to other states, Texas’ data indicates an early peak in April followed by a much higher one in July. Notably there are no data for the last two months.

Although Texas’ Division of Workers’ Compensation refers to the reporting entities as “insurance carriers”, the data actually include self-insured employers’ results.

  • Over a third of claims included a positive lab test for or diagnosis of COVID, but less than half of those were accepted by the insurer/employer (14% are still under investigation)
  • Half of all claims were incurred by workers in healthcare or social service, or first responders
  • The 2,065 accepted claims have driven $4.44 million in medical payments (as of September 27). That number, an average of $2,170 per patient, will certainly increase.

There are a bunch of other states reporting COVID claims, a vast improvement over what we had earlier this year. However, the different criteria used, different timeframes, different claim types and data provided make it difficult to get a clear picture of just how many claims have been reported, accepted, and denied; how many are med onlies vs lost time, how costly they are and on and on.

Key takeaways

  1. My best guess is between 200,000 and 300,000 COVID claims were filed by October 31.
  2. Going way out on a limb here, it looks like about a third have been or will be accepted.
  3. Benefit costs remain pretty low – significantly lower than other indemnity claims – although that opinion is based on slim data about claims still open.