Health Insurance Coordination is the Law

Medicare and Non-Group Health Plans

The Center for Medicare Services (CMS) has a process for injured workers to coordinate their healthcare costs with state and federal workers' compensation programs. See https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/InsurerServices/Insurer-NGHP-Recovery Based on my experience as an injured federal employee, this process is misunderstood and widely abused.

I sustained serious spinal and neurological injuries while in the U.S. Foreign Service. My injuries are managed by the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP). State and federal workers' compensation programs are widely abused. See https://www.fbi.gov/news/stories/workers-compensation-fraud-conspirators-sentenced-070219 and https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney-announces-federal-workers-compensation-benefits-fraud-charges

Injured workers, program administrators, claims examiners, and medical providers abuse workers' compensation programs. After a San Francisco physician explained his approach to workers' compensation medical reporting, I asked if what he described was not fraud?

"The whole fucking system is a fraud, Mr. Patterson," was his reply.

Former California Attorney General Xavier Becerra, in his Senate confirmation hearings to become Secretary of Health and Human Services (HHS), testified that Medicare was economically "fragile." (HHS administers and investigates waste, fraud, and abuse in Medicare.) Based on my experience this "fragility" is due to Medicare paying claims which are the financial responsibility of state and federal workers' compensation programs. Medicare is also economically "fragile" due to enormous waste, fraud, and abuse among its providers. Better coordination between Medicare, Group Health Plans, and Non-Group Health Plans (NGHP) is vitally needed.

Coordination of insurance is the law. Injured federal workers with injury cases at state departments of labor should follow the laws in their states. As a former staffer with the Indiana Employment Security Division, Indianapolis, it was my job to keep people working safely after workplace injuries. The Americans with Disabilities Act, federal labor laws, and other laws help keep injured and disabled workers employed.

Injured workers should not fear that a return to work will cause them additional injuires. Injured workers also should not fear that their workers' compensation insurance will decline payment of their medical expenses. State and federal labor laws provide injured workers with entitlements to medical care. This does not mean that an "entitlement" to medical care will always be easy to obtain when needed. Frequent turnover among administrative personnel at labor departments and insurance agencies cause delays and errors in decisions on payment of medical costs. Inattentive bureaucrats also pose problems.

I understand the frustrations injured workers and their families face with lengthy and often adverse insurance claim decisions by inexperienced administrative personnel. Cases are, however, highly winnable through the submission of highly detailed appeals.

In future articles, I will share policies and procedures for reporting on healthcare issues and work. I shed blood and nearly died for our country. I work with current and retired state and federal insurance officials on workplace injury claims. Information is essential in successfully getting the medical benefits to continue safely working as long as possible. We must all do our part to prevent Medicare fraud.

I am sorry I cannot answer detailed questions about individual injuries. Seek out your HR, state insurance and labor officials, and university legal scholars for advice.

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Award-winning economist James Patterson is a Washington, DC-based speaker. Availability: [email protected]