WSI’s legal folks are going around their own Medical Director to outside, part-time, contract medical directors when they want a certain opinion.
Thanks to Tony, I learned of the dispute between the North Dakota state fund’s medical director and that august entity’s legal department early today (hat tip to WorkCompCentral’s Peter Mantius); it took me quite a bit longer to get the back story on this mess.
And it is a mess.
Here’s the issue. When the claims and legal departments want a specific answer about a medical issue on certain claims they DON’T ask WSI’s Medical Director. No, they send it to one of two outside reviewers and skip routing it to, or even involving their in-house, full-time, employed Medical Director. By all accounts the Medical Director, a Dr Luis Vilella, is widely respected, known to be a “team player”, and interested in nothing more than ensuring the claimant gets the right medical treatment and the correct medical determination.
Evidently some claims and legal folks at WSI don’t like it when their view of a claim is inconsistent with that of Dr V, which is why they avoid involving the good doctor on specific claims. This has been going on for some months, until finally Dr V sent a letter about the issue to WSI’s director, the famous ex-state-trooper-now-workers’comp-CEO Bryan Klipfel. (the letter was obtained by the local paper in a freedom of information request)
In part, Vilella’s letter read: “How can WSI impartially adjudicate a medical claim when its own Director of Legal Services, Attorney Green, disregards litigation support that WSI’s Medical Director offers on matters of disease and injury causation?”
It would be bad enough if this was only on one claim – but it most definitely isn’t. In fact, sources indicate this has been happening for several years, including at least two incidents where WSI managers tried to alter his medical opinions. In addition, Vilella is being marginalized within WSI; excluded from meetings focused on medical topics, prevented from meeting with Sedgwick’s on-site auditors; and pushed three levels down below Klipfel in the reporting structure.
So we have the Medical Director in a work comp insurer – and a relatively tiny one at that – who reports up to a guy who reports up to another guy who reports up to a third guy who THEN reports to the top guy. In Klipfel’s defense, he recently decided to fix that really stupid reporting structure, and Dr V will be reporting directly to him.
That said, Klipfel knew legal and claims were marginalizing Dr V ever since former boss Sandy Blunt was run out of town on a rail. With Sandy’s departure, it appears as if the legal geniuses at WSI decided they were not only brilliant legal minds, but they were more suited to make medical decisions than a medical doctor.
After all, why would a state experiencing an explosive growth in workers’ comp claims, many of them complex, difficult, and traumatic, ever want to have a medical director in a position of authority? In actuality, the treatment of Vilella reflects something much more troubling than just a series of blatantly stupid decisions by claims and legal.
It is prima facie evidence of Klipfel’s – and the WSI Board’s – complete lack of understanding of the primary importance of medical in workers’ comp claims. Medical drives well over half of direct claims costs, and heavily influences the indemnity portion. Yet the acknowledged expert in medical was multiple levels below the CEO – who, by the way, had ZERO experience in work comp, or business for that matter, until he was appointed to the top job.
I don’t know Vilella, but I do know several other folks at WSI. The ones I know are good people, doing the best job they can in very trying circumstances. They really truly want to help injured workers.
It is too bad they are being “led” by idiots.