WC Nightmare--Here's a good read

I am so frustrated right at the moment and really need to vent to a group who can appreciate what I have been through. This is rather lengthy, so take a few minutes, kick your feet up, and enjoy.

We have an employee who went to the doctor in December of 1998 complaining of wrist pain (she is a baker for us). He told her it was carpal tunnel and she probably developed it at work. She came back to her supervisor with this information and for some reason, the supervisor did not report it until February of 1999. And WHEN the supervisor reported it, she listed February as the "Date of Occurrence" rather than December. The information was sent to the carrier who sent notice back saying they could not process the claim because the date of occurrence (February as the supervisor listed it) was AFTER the date of service (December). Rather than correcting the problem, no further claims were sent to the carrier despite the fact the employee continued receiving medical treatments.

Then in September of 1999 this same employee hurt her shoulder. She received treatments for this and for some reason the bills were either not being forwarded to the carrier or were not being paid for by the carrier.

I should interject here and explain that I did not start working here until January of 2001 and prior to my being here all HR was being handled by the accountant.

Back to the story--once I came on board all of this fell into my lap. The employee came to me saying she was still receiving bills, her name had been sent to a collection agency, etc., etc. So, Super HR person that I am, I go through all the paperwork, make all the appropriate calls, (oh yeah, did I mention that the carrier had gone bankrupt in the meantime and so claims were being handled by some state agency that took care of paying claims for bankrupt insurance carriers), did tons of follow-up, faxing, and everything else in between. Got the shoulder injury cleared up in March, 2001 and the carpal tunnel cleared up just a couple of months ago.

About one month ago I received a call from the provider in regards to the employee's carpal tunnel claim. (You're going to love this!!) They were calling me to tell me they were going to refund the money we sent to cover her care!!! Apparently I had called at one point to request therapy notes on the case. Notes were never sent (and I must have forgotten about them). Because they could not locate the therapy notes on this case, they couldn't charge for all the service related to this case!! (Now THAT'S why health care costs are sky high!!!) They would have to "eat" the entire cost of the service related to that case.

I was furious!!! "You mean I have spent all this time on something that you can't even charge us for because some doofus lost the notes?!?!" It wasn't even OUR money--it was the carrier's money. I wanted to tell her to KEEP the money. Please don't open up another can of worms with this case because I have spent the last year and a half working on a 3-year old case!!!!

(Deep breath.)

The employee comes up to me on Friday. "I wanted to ask you--my shoulder has never really stopped bothering me and I wasn't sure about calling the doctor about it because we had such problems getting my other claims paid." Why have you not said anything until now? Well, because it just seemed like a big mess before. Oh--but you'll say something now? Is that because you just took a large paycut because we lost a contract with one of our businesses and rather than laying you off we placed you in another position that YOU agreed to take a paycut for??? (Obviously I'm not saying this to her, these are the random thoughts going through my head.) Or is it because you've had a heavy softball season this year and want to make sure you get all kinds of great therapy so you're ready to go next year???

Things would be easier, of course, if the carrier that was handling the claim was the one we were still using--but it isn't.

Tell me again why I'm in HR.

Comments

  • 4 Comments sorted by Votes Date Added
  • Paige: The only thing that can possibly make you have a worse day is for you to think about the whipping that Southern Mississippi (wife's alma mater) gave the Illini on last Saturday down here. So, please do not let anything make you think about it. x:-)
  • That's it--twist the knife a little deeper.

  • Don D: You are positivly EVIL! x:D

    Paige: Keep your chin up! Remember all those little people you have helped over time. Don't let this bad apple spoil it for you (speaking of employee, not Don D.) ;;)
  • The employee is claiming the shoulder because he/she has experienced a wage loss and is looking for supplementation of wage. Refer the employee to the doctor, inform the WC claims representative what has been happening and request an investigation in hopes to get video of the baseball games. If sufficient evidence can be found that the employee is able to play baseball and do other things outside of work then you will have enough ammo to deny any further treatment and possibly even recuperate some monies or prosecute for fraud.

    YOU MUST BE VERY ASSERTIVE WITH THIS CLAIM TO PREVENT THE "RIPPLE EFFECT". If other employees see your company rolling over, they will follow suit. Sounds like you like to get after it and take care of business. Keep that same attitude and effort and it will pay off. You are in HR because you are on the ball and do a good job, don't forget that.
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