Actually this should be a Workers Comp claim

Dec 15, 2018

  1. somarco
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    somarco That Medicare Expert Guy

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    Been away from group (mostly self funded) for too long so I would appreciate the answer.

    Injured on the job but does not file WC claim. Too many horror stories about long waits, unable to get proper care . . . the same complaints people have about govt provided, taxpayer funded health care.

    But I digress.

    So let's say Brenda goes to the Urgent Care facility with a broken bone. How did you break your hand? A student hit me with a text book.

    Does UC treat you, file with your insurance that then subrogates against WC? Do they refuse to treat since it is obviously WC? Do they treat and bill you for cash, let you sort it out with WC?
     
    somarco, Dec 15, 2018
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  2. adjusterjack
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    adjusterjack Guru

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    How UC "bills" it is up to UC. You'll have to ask UC what the billing practice is.

    How it's covered depends on the terms and conditions of the medical insurance (which may differ from plan to plan) with regards to work related injuries.

    The answers to those questions are in the policy/contract/plan booklet/whatever.

    Read it.
     
  3. Markthebroker
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    Markthebroker Guru

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    Public schools, along with all other government entities, self-insure most things. They self-insure work comp, as far as I know.

    Private schools, on the other hand (hopefully) purchase insurance. I insure several.
     
  4. somarco
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    somarco That Medicare Expert Guy

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    Should have been more clear.

    Group health insurance typically is non-occ. WC (workers comp), not UC (unemployment comp), claims are generally not a covered item under an employer group health plan.

    Doesn't matter if the plan is fully insured or self funded.

    Many years ago stop loss reinsurers tried to develop a 24 hour product. Never got off the ground unless someone figured out how to make it work since then.
     
    somarco, Dec 15, 2018
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  5. adjusterjack
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    adjusterjack Guru

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    In your original post UC referred to Urgent Care and your concern was

    To which I responded that you would have to ask the specific Urgent Care facility what its billing practice is. If all you want is unverifiable speculation I would speculate that the Urgent Care facility would not deny treatment to an injured patient and would bill whatever insurance the patient presents at the payment window (or expect the patient to pay and seek reimbursement). What any given insurance company does with the claim depends on the terms and conditions of that policy. If that policy excludes occupational injuries and it is clear from the details presented by the patient that the injury is occupational the claim will be denied, the patient will have to figure out what to do, and the Urgent Care facility will send him to collections if the bill doesn't get paid.
     
  6. somarco
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    somarco That Medicare Expert Guy

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    Nope, just an example.

    Could have been ER, hospital inpatient, doc office. Provider setting is not the issue. The question is how a claim that is (most likely) a WC claim handled by a group health carrier.

    Either I am not getting my point across or reading comprehension is a challenge for some.

    OK, your answer is not helpful.

    And you STILL don't understand my point.

    You can leave this thread at any time and won't be missed.

    Goodbye.
     
    somarco, Dec 15, 2018
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  7. adjusterjack
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    adjusterjack Guru

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    No, that wasn't the question. Let me quote it back to you:

    You do see that the question was about a provider's billing practice, don't you?

    That. ^

    Now that you have asked a question that you didn't previously ask, I believe that I answered it when I wrote:

    It's a simple concept. Claims that aren't covered by group health insurance (or any health insurance) are denied.

    Anything else you'd like to know? I'd be happy to help.
     
  8. leevena
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    leevena Guru

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    If a medical plan receives a claim that they believe to be a workers compensation claim they should decline to pay and provide the reason via EOB. If the medical plan pays the claim and the determines it was a WC claim, they will reverse. There are different methods as to how.
     
    leevena, Dec 15, 2018
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  9. somarco
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    somarco That Medicare Expert Guy

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    Thanks Lee. That was the clarification I was seeking. Which is why I posted in employee benefits, not the P&C forum.

    My wife works in a school system and one of her co-workers was indeed hit by a student. The lady did not want to file a claim with WC for the reasons given in my OP. She had filed a WC claim last year and her medical issue is still unresolved. So she is seeking treatment under their (self funded) group plan.

    Wife asked me how the claim would be handled. I gave her an answer but it wasn't definitive.

    So I came to the source of all wisdom.
     
    somarco, Dec 16, 2018
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  10. leevena
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    leevena Guru

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    For what it is worth, something about her story does not feel right, especially her concerns about long waits and less than quality care. Today most urgent care centers will treat WC with minimal wait times.
     
    leevena, Dec 17, 2018
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