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Is group health paying for medical care for work comp injuries?

According to a study published in the December Journal of Occupational and Environmental Medicine, the answer is yes – to the tune of at least $200 million dollars annually.

The researchers concluded that “zero-cost” claims – those that were filed but did not result in any payments from the workers’ comp insurer or TPA – showed higher than expected medical expenses in their group health plans following the date of injury.  Some may, and undoubtedly will, argue that just filing a claim does not mean it is “real”, that many if not most of these “claims” were not occupational in nature and therefore there should NOT have been work comp dollars spent.  Therefore the dollars spent after the date of injury SHOULD have been higher, as there was an injury, it just wasn’t a work comp injury.

Well, not so fast.  These were actual, accepted workers’ comp claims and not attempts to file claims for non-occ injuries.

That being the case, I’d suggest the author’s finding, that about 0.7% of workers’ comp medical expenses have been paid by group health insurers, may be correct.

What does this mean for you?

With group health medical loss ratios fixed at no less than 85%, health plans have dramatically increased their efforts to identify and avoid any and all medical expenses that are not really truly absolutely theirs. Expect much more diligence on the part of those insurers, and a lot more subrogation efforts in the future than we’ve seen to date.  

Thanks to Insurance Journal for the tip!

Request – before you argue, please read the ENTIRE study, available here.  It is pretty well done.

7 thoughts on “Is group health paying for medical care for work comp injuries?”

  1. No argument here. I know for a fact of claims that have lifetime indemnity payments but no med billing for years. When a yearly activity check is done, the clt readily admits he is getting treatment and prescriptions for his compensable permanent injury. When we dig deeper and contact the provider requesting him to bill us not the GHP, the most frequent response is that the care given is across the board not just for the WC related Tx and it would be too much of a burden to bifurcate the billing.

    1. Thanks Tony – you’ve pointed out the need for a future research project, one that may well turn up even more group dollars spent on workers’ comp. I’d guess the group health payers may decide to deny these claims as they are work comp related, and the claimant received a settlement out of which s/he should be paying their bills.

  2. There are also many claims filed under workers compensation that should be paid under group health. Just because someone began to have pain while at work does not mean that work was the cause of the condition. Someone may have an acceptable incident but then the diagnosis and treatment for that claim is deemed to be not work related due to the mechanism of the injury and therefore should be paid under group health.

    Also work comp is only responsible for getting the claimant back to baseline before the injury. This does not mean that in the future the claimant will not need to obtain treatment for the pre-injury condition specifically when degenerative in nature.

    1. Good point Cheryl – this may be especially true for back conditions; many of us older folks have bulging discs without any pain, yet this “symptom” may be used to justify treatment for a work comp claim if there is pain after lifting something at work.

  3. Joe, From the group health carrier’s point of view, if it is really a workers’ comp claim, they can subrogate to the workers’ comp carrier. The question here is whether they do it (some carriers may not put the effort into subrogration) and how they can identify possible claims that could be subrogated, especially if the claimant doesn’t alert them to this issue or if the employer specifically tells the employee to file the claim with the group health policy.

  4. Some workers may prefer to avoid the scrutiny that results (or is perceived to result) from a WC claim investigation. Depending on the state, this could range into areas like immigration status, use of mandated safety equipment, use of controlled substances, or other medical conditions.

  5. Joe,
    It’s important to note that many times it’s the Employer themselves that creates this scenario; especially those that have self-insured Group coverage. There are many “medical only” or “record only” claims that are never reported as a WC injury.

Comments are closed.

Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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