A Maze of Pain

Physicians and injured workers say city-hired bureaucrats are denying them needed medical care — for years.
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Posted December 18, 2013 by ERIC GRIFFEY AND EDWARD BROWN W/ Photos by Lee Chastain in News

It’s not just the injured workers who have expressed frustration with CorVel. Physicians and caregivers complain that CorVel and the Texas workers’ compensation system have a multitude of ways to interfere and disrupt the relationship between doctors and their patients.

One local physician, who asked not to be named, said the workers’ compensation system has three levels designed to delay and deny care at every turn. At the first level, he said, caseworkers and doctors hired by third-party administrators “downcode,” or lessen the severity of the diagnosis (calling a torn muscle a muscle spasm is a common example), binding the employee in a bureaucratic web that keeps all but the most desperate workers from reaching the treatment phase. One example often cited by CorVel’s critics is the delayed peer-to-peer interviews.

“Patients can easily get tied up for a year here,” said the physician.

Hall: “The whole system is broken.”

Hall: “The whole system is broken.”

The second level deals with the types of treatments offered to workers. Years of workers’ compensation legislation have created strict guidelines that emphasize medication and therapy over surgery whenever possible. According to the local physician, the use of medication as a substitute for surgery is partly to blame for a rise in problems related to abuse of prescription drugs.

When CorVel initially denied her doctor’s request for neck surgery, Timmons was sent instead to what she called a therapy camp. The pain-management therapy course consisted of eight hours of therapy a day for 10 days.

“You have nap time, you have lunch time, and a therapist,” she said. The therapy helped she said, but only temporarily.

At the third level, the system kicks out injured workers entirely by declaring that, in essence, there is no more to be done for them and they have reached “maximum medical improvement.” At that point, the worker is assigned a final “impairment rating” by a state-appointed doctor, who is not required to have any previous experience working with the patient. The rating determines the final level of benefits to which the worker is entitled.

While Texas requires an evaluation of maximum medical improvement at 104 weeks after the injury (when temporary income benefits end), third-party administrators are allowed to push for such evaluations to be done much earlier. Most injured employees end up confronting a quicker deadline. In Fort Worth, the deadline is one year. But injured workers must petition the city council to extend their leaves of absence. Such requests create an added burden for injured workers. As recently as Dec. 10, the city council had three extension requests on its agenda.

Wilkerson, from CLEAT, said the type of delays the physician referred to go beyond a simple inconvenience. He believes a colleague died partly because of delays built into the Texas workers’ compensation system. (In that case CorVel was not the company involved.)

Wilkerson said that a timely surgery could have saved the life of that colleague, a Houston deputy sheriff, but a third-party administrator delayed the procedure.

“Third-party administrators are just a bunch of pencil bums getting paid to say no,” he said. “Is their job to say no or to be a third-party administrator?”

Problems like these sometimes force workers to hire lawyers at a time when their finances are already strained.

“You can really hurt these people financially,” said Barbara Lombrano, an Irving-based attorney who has been practicing workers’ compensation law for more than 20 years. She believes the system often prevents employees from getting back to work.

According to Lombrano, the system is set up to make it easy for a third-party administrator to dispute job-related injuries in court.

“Why not roll the dice?” she said. “Now there’s really no penalty for [third-party administrators] dragging their feet. Now we have to prove that the [third-party administrators] intended harm to the client. How do you prove that?”

The burden of proving that injuries are work-related falls on the workers, most of whom aren’t prepared to fight a legal battle while still recovering from an injury.

“We have to show acceleration of the injury [due to work],” she said. “We have to link the injury with the diagnosis. The MRI might come back normal, but the claimant is still in pain.”

Lombrano noted that shoulder and knee injuries are particularly hard to diagnose using certain types of imaging scans.

She and her clients must provide what’s called an “extent of injury letter” from the worker’s physician outlining the injury in great detail. Since doctors are not paid extra for this service and have little knowledge of legal terminology, these letters often fail to help the worker.

“We have to describe the mechanism of injury and be 100 percent consistent,” she said. “The carriers have the money to hire experts to say all this stuff is pre-existing, that it’s a coincidence. The claimants can’t afford [their own experts].”

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Without federal guidelines to govern workers’ compensation, each state chooses its own policies. Texas law requires that each city provide public employees with workers’ compensation coverage, leaving cities with the option to self-insure or hire a commercial insurer. Since 1974, Fort Worth has opted to self-insure.

“The city uses its own funds to pay workers’ compensation benefits to employees,” said Ron Josselet, Fort Worth’s occupational health and safety manager.

“Being able to self-insure is a cost savings to the city,” he said. “The city does not have to pay premiums, and presumably a profit, to a commercial insurer or to a risk pool.”

The city chose not to renew its contract with Contract Claims Services, the company that did the job before CorVel, because of a sharp rise in workers’ compensation costs. Between 2009 and 2012, costs rose by more than 50 percent in Fort Worth. After reviewing 12 competitive bids, the city went with CorVel, which proposed to  charge the least of any of the bidders.

Texas has increasingly limited the availability of healthcare to injured workers through legislation for the past 20 years, with only a handful of efforts to rectify the problems.

“The whole system is broken,” said Steve Hall, president of the Fort Worth Police Officers’ Association. “CorVel is just our piece of the pie.”

Hall said that over the years he’s made multiple complaints about different workers’ compensation issues to the Office of Injured Employees Counsel, a resource created by the Texas Legislature to help injured workers navigate the workers’ compensation system. When the state office ignored his phone calls, he took his complaints to State Sen. Wendy Davis, who, he said, was also ignored.

“They have reps who are supposed to assist injured employees in the red tape of workers’ comp,” he said, “but they seem to have a nasty habit of not returning phone calls and ignoring complaints.”

The Office of Injured Employees counsel did not return phone calls from the Weekly.

Amy Lee, spokesperson for the Texas Department of Insurance, said the Texas workers’ compensation system in the 1980s was becoming unsustainable due to a high volume of claims, which often ended up in court, clogging the legal system.

The 1989 Texas Workers’ Compensation Act made it more difficult for workers’ compensation cases to get to court by creating measures such as a three-judge panel to oversee hearings and reviews to settle disputes. Since the act became law, less than one percent of workers’ compensation disputes end up in district court, according to Lee.

In 2001, House Bill 2600 required physicians treating injured workers to be on a pre-approved doctors list.

“Any doctor in a network sounds good, doesn’t it?” said Lombrano, who added that third-party administrators can and do “pick doctors they know they can count on [to deny treatment].”

Injured workers battling limited access to lawyers and treatments were thrown legislative bones in 2005 and 2011.

The 2005 legislation created the Office of Injured Employee Counsel to advocate for injured workers lost in the system — the agency that Hall said had failed to respond to concerns expressed by him and Davis.

In 2011, the legislature created a law that expedites treatment process for first responders.

“We’re in a state where lawmakers are afraid of being painted as encouraging lawsuits,” said Wilkerson, president of CLEAT. “It’s too bad cities didn’t work as hard to find solutions as they did to prevent [medical] care.”

Patricia Kolodzey, a Texas Medical Association legislative affairs staff expert, told the Weekly that the 2005 bill brought “considerable changes to the system, but more work needs to be done.

“TMA continues to work legislatively with the Texas Division of Workers’ Compensation during rule-making to ensure that any law or regulation does not deter or delay physicians from what they do best: treat their patients,” she said.

Though data obtained from the city shows that CorVel has reduced its workers’ compensation payouts, the figures don’t tell the whole story. The numbers don’t factor in other costs such as overtime pay for replacement workers and temporary income benefits.

“Because officers are unable to work due to injury, someone has to do that job,” said Hall with the Fort Worth Police Officers Association. “More often than not the decision is made to run short-handed, which means fewer officers available to answer calls, longer response times, and lower customer service.”

Gillette said he should have returned to work six months ago. He is still being paid his salary of $98,000 annually. Any supervisor called in to cover his  shift probably makes about the same money — unless the extra duties puts him or her beyond 40 hours a week, when the pay goes to time and a half.

“[Other officers] are all eating it up, because they’re getting overtime,” he said.

The surgery he needs to repair his neck would cost roughly $5,000, according to a Medicare pricing guideline.

The Texas Legislature isn’t expected to review the workers’ compensation system again until 2021. State Rep. Lon Burnam has been fighting the current workers’ compensation system for decades.

“Delayed treatments mean worse injury and slower recovery time,” he said.

He sees the system as being largely beyond repair, because, he believes, lawmakers are beholden to big medical businesses.

“In Texas the worker is screwed and unfortunately [legislators] just can’t help,” he said.

 

Fort Worth freelance writer Edward Brown can be reached at ejb0017@yahoo.com.


21 Comments


  1.  
    JN

    FWW might wish to explore the percentage of “recommended” spinal surgeries which are successful. (definition: substantial permanent recovery from pain and ability to return to full time work status). I would suggest that upon investigation, the author (and the patients described above ) might concur that the ‘best” spinal surgery is NO spinal surgery. Patients should follow conservative treatment recommendations for physical therapy, weight loss, etc prior to undergoing an irreversible and potentially risky surgery. My problem with spine surgeons and orthopedic surgeons in general is that they financially control every aspect of WC treatment evaluation to an alarmingly self serving degree. Many own shares in clinics, hospitals surgery centers and MRis outright –so it is no surprise that a diagnosis supporting a multi thousand dollar surgery (some up to $75,000-100,000) is reached. What happens if the patient is a victim of failed back surgery syndrome? (.ie. the surgery does not work). Frequently those patients are thrown on the disability ash pile with a few addictions to strong pain medications as an added burden( at public expense). I do feel that the Health Insurance industry is corrupt and complicit in some of this as well (in a self serving way), but this topic is complex and deserves mor in depth analysis.




    •  
      DD

      When you have three different types of imaging studies and conservative measures have failed, you have the surgery. PT will not fix a blown disk or torn ligament. It sounds like JN is the one with the big red DENIED stamp. If someone has never had to navigate the hell Chip is enduring, they have no right to speak on the subject. It’s a nightmare realized.




    •  
      Eric Griffey

      Can you email me? I’d love to pick your brain on some things. Thanks, eric [at] fwweekly.com




  2.  
    Jill

    CorVel wouldn’t return any phone calls? Did you call them at midnight? 6 pm on a Saturday?




    •  

      We called them at every possible hour of every day during the week for two weeks.
      They knew we called and why.




      •  
        weely reader

        This subject was well covered by Brettt Shipp on WFAA in 2003, and resulted in re -formating (reorganizing) the TWCC by removing an obvious 75 year old insurance industry advocate (former insurance agency owner-I believe) as head of TWCC with a former Texas Medical Board administrator (also elderly) who allegedly over saw medical board abuses of the health insurance industry( which was instrumental in filing anonymous complaints against innocent physicians who sought more comprehensive care for their HMO and worker’s comp patients). If anything, the abuses are even worse now, in the opinion of some. The insurance industry remains unchallenged by either party and has a huge lobbying presence locally and nationally. They will argue that their profits are “minimal” but they continue to have escalating annual retrurns, and multi-million dollar CEOs. One economist pointed out that if the WC and other insurance companies were not profitable-they would have such exponential growth in numbers of companies, TPAs and other associated support organizations. It would probably be best if there was limited self referral by certain members of the medical community,but re-imbursement limitations are responsible for that ethical dilemma as well. In short, Edward CorVel doesn’t even need to acknowledge that you exist, because they are in complete control.




  3.  
    Beck

    Chronic pain/ can’t find the pain go to Dr. Howard Cohen PRIDE- Dallas. Treats a lot of injured soldiers (IED’s). The ONLY Dr. That has helped me.
    Eff the city, department, and Corvel. JN/DD I’ve fought the nightmare for 5 1/2 years. DD, surgeons will LIE…2 year statute of limitations medical malpractice…period. JN, Sunshine Act (8/13) is supposed to expose these hidden financial ties between Dr. and corporations.
    FWPD, AFLAC does NOT cover on duty injuries for p/t jobs. Also, sign up for long term disability insurance with the city. Crap happens, stay safe;)




  4.  
    Beck

    I bet the Mayor didn’t have this problem when she fell off her bike and bumped her head…SMH




  5.  
    Jefe

    Hmmmmmmmmm.
    I guess one conclusion that FWPD officers could make from all this is to not get hurt on duty, whatever that takes. You wonder how much better Sgt Gillette might be if he hadn’t risked his health trying to subdue a miscreant citizen of a city who views its employees as disposable rather than valuable.
    Anyway, Sgt Gillette can now “endure” his job related, pain infused, well-deserved, involuntary retirement……oh wait, the Mayor and Council messed that up for the City’s “most valuable resources” too.




    •  
      JN

      The worker s comp system has more shady characters and sub plots than a Charles Dickens novel. The insurance industry is quite powerful and has an extensive lobby. In the G H W Bush presidency , doctors were forced into a unique sort of “antitrust’ category which would not allow collective or essentially individual bargaining with health insurance companies. All independent physician reimbursements could be prorated on Medicare rates (which are not very high). This allows for escalating profits by “not for profit” hospitals (which successfully argued that they take a “hit” with indigent care–but charge everybody else three to ten times the going rate), pharmaceutical companies-(cost of research don’t you know), and Health insurers(who never fail to make incredible profits annually) Any so called “reform” is aimed at further marginalizing physicians income–ignoring the other primary three cost driving industries. (Is it any coincidence that these “profitable” industries all support ACA- Obamacare?) Workers comp in Texas was extracted from the PI attorneys provenance in the 1990s by the legislature under the “any willing provider” guise. In other words, if you were an injured worker, you did not need to sue your boss, you could go to any physician for an honest evaluation. Which was fair enough umtil these rights were erroded during the Perry years when worker’s comp insurers decided to get TPAs (third party administrators) to terrorize doctors and workers by extracting money from the physicians re-imbursements ( for unspecified “administrative” work–like doing nothing but attaching their names to the physicians reimbursement check and extracting10-15% for NO function e.g.) and denials of medical procedures and payments. As if the physicians were not demoralized enough, the TWCC (essentially a bureaucratic arm of the insurance comapanies) and the TDI (which is useless) teamed with the medical board to look for “overutilizing physicians”–in other words-physicians who had more workers comp patients than the insurance industry thought they should have. Filing anonymous complaints with the medical board to get rid of the pesky docs. The surgical docs decided to diversify and bought shares in hospitals, surgery and imaging centers to offset surgical procedure income loss(who can blame them?) The insurance companies see the end game of essentially employing these docs in the next decade or so and assuming control of their practices until they can make a profitable exit (merger acquisition etc). Independent docs are worn out by the insurance company tactics and really do not want to be on the phone all day for phoney “peer to peer ” consults with paid ins co employees -for little reward and refer their patients to the surgical docs (who have found a way to make a profit). This leaves the patient in limbo. CorVel has marketed their “package” to cities and large businesses under the guise of “exclusivity” which means they only allow a certain number of “providers” in their network–this essentially further slows the evaluation process for the patients (sound familiar-like ACA-ACO, etc.?). The cities and businesses pay less in premiums. Are the providers the “best”? Some would say,not…




      •  
        weely reader

        Limiting the pool of providers and keeping inactive or deceased providers on a roster of providers while denying enrollment to potentially new and interested providers (saying the provider pool is full)– is a time honored con game of all health insurers. This limits the injured or ill parties access to care and makes the insurance companies more profitable. This is also the chosen “tact” of insurance companies under ACA-Obamacare under the ACO paradigm. Also who “judges” the “quality” of the provider pool? (Your good buddies in the insurance industry and government) How reassuring…




  6.  
    Mary G

    After reading this article I was first amazed that the worker’s comp program was CONTRACTED out in the first place. That this is happening in Texas does not surprise me, sad to say. The whole point of worker’s compensation programs is to get the worker back to work, if possible, as soon as possible, The fact that this contractor is not doing that by stalling surgeries & playing phone games is a waste of the taxpayer’s money as well as causing personal hardships to the affected employees. I work for the federal government & I thought our OWCP had some issues but this is unreal. The city employees need to take this to a higher level and beyond if needed as well as litigation.




  7.  
    Ryan

    Yep, they denied my claim for knee surgery after mangling my knee kicking a door in on a call… They were terrible to deal with. Glad I finally got it fixed, on my own dime.




  8.  
    skeptic

    Welcome to the BIG state and local Government-Health Insurance Complex! BTW Mary the Dept of Labor workers comp insurance is one of the most difficult in the nation to deal with!




  9.  
    skeptic

    I can see that the liberal leaning FWW is working pretty fast to “bury” this “cover” issue (another more maleable subject has already appeared) ;It is clearly not going the FWW socialistic (one payer system) way! I hope that the injured parties featured above are not feeling “used”. Too bad that the authors and editors could not build on previous investigative journalists’ work to actually reveal the truth. (That WOULD be asking a great deal, I suppose). My advice to patients is: Do not depend on your insurance company or your employer to take care of you. Seek several second opinions, ask around. Don’t depend upon some charismatic provider to send you into an irreversible medical situation which you may regret!




  10.  
    Chip

    Hello,
    I am a line of duty disabled deputy sheriff out of Minnesota. As I read this article, I could not help but to get furious. I have been disabled since 1986 after the squad that I was operating was struck head on by a drunk driver.
    Texas is not the only state that this kind of crap goes on. Minnesota can stand along side Texas in the way that the county that I was working for when I was injured. I had never had to deal with the workman comp system until then and I had a rude awakening.
    When I was injured, I thought that I would be taken care of medically. I could not have been any more wrong.
    I could write a book here of what all I went through and the results that I now have to deal with each and every waking second of every day. When I get to thinking about it, I have to be careful as I have a bad heart condition of which I can lay the cause to the lack of medical care that I received for my injuries.
    My heart condition started when I was trying to get approval from the work comp overseer to get a mri done for what the doctor thought was a increase in pain contributed to a worsening of my condition from the injuries sustained in the accident. I called and called and called leaving messages with the company and after over a week of calling begging for permission to get the tests done, could not take the increased pain any longer and went into the ER at about five am one morning and explained to them about the need for a mri, they put me in a room and started to check me and all of a sudden, the nurses and doctor went ballistic. It ended up that I had been having a heart attack the entire time. I ended up having a quad by pass and over the years since, have had to deal with atrophy of my hands, arms, neck and upper back from the injuries that the county actually had the nerve to say were not there and had accused me of faking my injuries. My heart was damaged by the heart attack or I should say heart attacks as the doctors could not say how many I had suffered through while begging the company to get the mri done!
    During that time, my heart continued to deteriorate and in the fall of 2010, while at a funreal the guy that was the sheriff while I was trying t get help, came up to me and jumped on my back and started to hit me, I was shocked. I went down to my knees because I felt my heart start to flutter. Finally he let me alone. It was embarrassing as there were sworen officers who just stood by and watched even though I was looking into their eyes and trying to get them to stop him. They did nothing. Then about four months later, with my heart going in and out of the flutter feeling and causing me to have to go down to my knees to avoid falling, I suffered another heart attack which caused me to die three times in one night. Fortunately, I was at the hospital when that happened and they were able to get me back.
    I attribute the last heart attack also to the then retired sheriff who jumped on me. I still can not believe that he did that.
    After he had done that, there was a dinner for the deceased and the guy came up and started to tell me that the atrophy of my upper extremities was all the result of getting older?!? The latest doctor who finally gave a crap about the atrophy which by now was very obvious, would have argued that point with the guy for sure. I was trying to swallow some food but the fluttering made it hard to swallow and I started to choke and he turned and walked away. Thank the lord that I had a glass of water to wash the food down.
    It really is a sad state of affairs when it comes to how injured officers are cared for in this country. I would suspect that my story is not the only horror story in Minnesota.
    I knew that the retired sheriff did not like me as I had supported a fellow who had run against him for the office of the sheriff. I knew that he had been unhappy about that but it had been at least six years since and I thought that he would have grown past that by then. As a matter of fact, when he walked up to me, I expected that he was going to shake my hand and not jump on top of me and start beating on me! After all this was in a church and at a funeral!!! I feel my heart starting to pound hard so I have to stop. Like I stated earlier, this is just a small part of how I was treated after having a legitament injury while on duty.
    Also, in my case, I have to believe that the county would have preferred that I had died in the accident as it too would have been much less expensive for them. Even though, I had to pay for most of my care or I would have died a long time ago.
    When I hear a politician say that injured officers are taken care of, I have to go away from where ever I am to avoid getting to worked up. As you can probably tell, my mind was also effected over the years as well. I try to think straight but sometimes when I get upset over all that happened since 1986, I get lost.
    The worst about all of this is that my loved ones have had to watch my deterioration over the years and it is obvious that all of what has been done to me is going to cut my life short. It was very hard to come back in 2010 and I am afraid that I do not have enough strength to go through that kind of thing again.
    Thank you




  11.  
    JTW

    This article exemplifies how worker’s compensation cases are handled in Texas. Employers have the luxury of hiding behind their insurance carriers. They can cut worker’s compensation costs by choosing the lowest cost provider and at the same time separate themselves from the injured worker. Medical care is sacrificed for cost savings. Injured workers are given endless denials instead of treatment.

    Texas legislature has acknowledged that worker’s compensation system is broken but fails to enact any real legislation to actually help injured workers. The recent Texas Supreme Court decision (Texas Mutual Ins. Co. v. Ruttiger) further demonstrates how inured worker’s rights continue to be eroded. This decision prevents bad faith or unfair practice claims against worker’s compensation insurance carriers. Tortious conduct by an insurance carrier will now go on unchecked and clears a path for them to act with impunity.

    I am a police officer employed for an agency near Austin. I sustained a training/work related injury in 2011 which resulted in a herniated cervical disc. I have been subjected to a deluge of bureaucratic red tape. The Texas workers compensation system is so convoluted with procedures which are designed to outright deny cases involving any type of spine surgery. My case is similar to three other officers at my agency.

    My case is currently scheduled for a benefit review conference (BRC) and a contested case hearing (CCH), requiring costly attorney fees. I have no other recourse but to hire an independent attorney since the Texas Department of Insurance (TDI) – Office of Injured Employee Counsel’s (OIEC) Ombudsman Program does not provide licensed attorneys to help injured workers. I previously contacted an ombudsman and was not impressed. OIEC is staffed with “qualified” personnel who have completed a “training program” who can “guide” you through the process. No thanks, I rather be represented by someone who is versed in statutory and case law. I really believe that the insurance carrier attorneys, the Division of Worker’s Compensation (DWC), or even TDI will not respect you if you are not duly represented by an attorney.

    My employer’s insurance carrier requested a designated doctor’s (DD) exam whereby an “independent doctor “, or general practitioner, rendered an opinion not based in a field of specialty/experience but according to official disability guidelines (ODG). The DD completely disregarded my complaints of pain and my treating doctors’ recommendation for surgery. The DD stated that I was at MMI and no further treatment could be offered. I have appealed this decision and now waiting for a BRC.

    While waiting for my BRC, my treating doctor has sent requests for surgery which have been met by peer review denials (X3). “Independent doctors” who do not examine me, but again review ODG, which explicitly does not recommend surgery for a majority of spinal injuries. Using ODG simplifies the process of the peer review and makes it easier to deny surgery. My doctor tries to appeal. which is referred to TASB, who forwards to an independent review organization (IRO), who then ultimately forwards my case to another designated doctor who quotes (verbatim) the denial of the previous peer review doctors. I have appealed this decision and now waiting for a CCH.

    I have failed all other conservative and pain management (epidural injection) options. So in the mean time, I just have to deal with the neck pain and the sleepless nights caused by my arms going numb. Hopefully some day I will get approved for surgery before the pain medications cause serious kidney/liver problems or even worse, permanent/irreversible nerve damage from a herniated disc.

    The insurance carrier is hoping that I will eventually give up this exhaustive process, like my other fellow officers who eventually used their private insurance and paid the $3000 out of pocket deductible.

    I feel a personal injustice has been done and I am not going to give up this fight.




  12.  
    weekly reader

    This article illustrates the folly of those who believe that their employer, workers comp or other health insurers will take care of you. In recent decades health providers have been reduced by government and insurance industry lobbyists to mere servants of the system (by insurance industry design). I would say that if you have the out of pocket deductible and a private insurance plan, this would be the time to use it…





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