ER and Work Injuries

The Emergency room visit workers comp combo

I was going to make one long blog post, but it got to long. I have to change this up a little, divide and conquer this information.

When you end up in the ER, its not because you like being there (I hope). Your visit will fall under personal reason, accident or work injury. Each one of these are a little bit different.

Workers Comp.

Lets start with the two most common types of workers comp

State Industrial and Self-insured. In Washington state you will most likely fall under these two categories if you are injured on the job.

We have a list of companies at Washington state on the Department of Labor and Industries website that will list whether your claim will be filed under your employers own self-insured plan or if you will file under Workers Comp/State Industrial/L&I. The person taking your information at the front of the desk will most likely look at this list and see which you fall under.

You will get a form (unless you were given one from work). That form will have you fill out information about you, your employer and the nature of the claim. In Washington state this is carbon copy and you need to press hard when you write and clearly in the little-itty-bitty places they have for you to write.

You will be asked a million times: Where did it happen, when did it happen, what were you doing.

If you need a surgery, they are going to ask us all those questions as part of the verification process when we call to see if your surgery is approved.

Now a days, I would recommend you take a picture with your phone of the claim application filled out. Especially the ID number. At some point all this must be filled out by the ER doctor. Humans make mistakes and papers get lost.

You will need to follow up on this to make sure everything is paid and your claim is actually initiated. Don’t depend on your employer.

If it is through a state industrial, you will call the state. If it is through a self-insured group, you will need to call the benefit administrators for that group.

Make sure you are receiving information and follow through with everything. Missing one letter/correspondence  could have your claim closed and you stuck with bills and the hassle of having it reopened.

Either one of these groups will assign you to a claim manager. That person is in charge of your case. When we go to obtain authorization information for services, we will need to contact your claims manager.

Our State industrial has a group that reviews and recommends whether to allow some services or not. Qualis reviews services like expensive services to see if your healthcare providers have enough documentation to warrant doing the service. And to see that they tried everything else with relief of your symptoms. They send their recommendation back to the state claims manager who makes the final decision on the recommendation.

A self-insured group may or may not have an outside group to review cases.

In 97% of the cases, things go smoother then you might think, albeit slow.

In Washington state we also have a lot of people that work on the water. The Washington State Ferry system is the largest(?) in the US. Fishing vessels. Deadliest catch, you can tour on one of the boats down at fisherman’s terminal in Ballard. Cruise ships. Cargo ships. Since we also service Alaska for medical needs, we can get a lot of those same groups down here for services.

If someone has an accident working over water, it is not covered by L&I/Workers comp. They fall under “the Jones Act”. I find that the companies have a way to work these claims under the Jones Act that is similar to the workers comp route. But it is a different legal animal all together. When you are working with your doctors or calling for appointments, mention this is a Jones Act claim and not a typical workers comp. There is a good chance the person you are talking to has to talk with someone else. In my 5 years of working in patient access roles where I would have been exposed to this type of insurance, I think I only had 3 or 4 people fell under the Jones Act.

If your side hustle is to get a shrimp boat because you, Forest, are inspired to be a shrimp boat captain, you and your crew are going to fall under this weird grey area of the workers comp spectrum.

There are two more that kind of combine. If you have regular health insurance, you will need to complete all the claims stuff they send if you have no insurance and need to use your regular health insurance to pay the claim. An insurance company has up to 1 year to take the money back from the providers. If you think you got away with it, 365 days later, you might get a surprise that they figured out this was a workers comp. It might actually be longer then that, because the hospital is going to send you that bill that now has been unpaid. Be truthful and prepared to appeal. This includes Medicare.

The reason I bring this up is that we are all trying to save for that first deal. Taking on these gig economy jobs. But, read that fine print. Uber, your car insurance won’t pay from the time you get the call to pick the rider, but Uber wont pay until you pick the rider. There is a time in there that is no mans land. I have had people come in that worked side hustle gigs where on the website it says - the delivery item is insured, your car is insured, but you are not insured if you get injured outside of the car, even when in the act of delivering.

When you are doing gigs/side hustles, read the fine print. Be prepared for a lot of extra leg work to get things paid. You may even have to make some type of minimum payment to keep from going to collections until it is resolved.

When dealing with a job or work injury, you really have to stay on top of being your own advocate. And keep track of those ID numbers.

If you are under a long-term therapy, check every once in a while, to make sure that everyone is talking to each other. I can’t violate HIPAA, but if I could, you would be way more mindful of checking to see if the hospital is getting paid or not. Sometimes, because it is expected to take a long time to get paid for these claims, things grow really large when something was missed or miss understood early on.