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In this Emerging Issues Analysis article now available on the LexisNexis Bookstore for purchase, Karen C. Yotis, Esq. examines the 2011 legislative reforms to Illinois workers’ compensation from a claims-handling perspective, as explained to her in an interview with Mark Walls, the Assistant Vice President of Claims at Safety National. A partial excerpt follows:
Illinois Workers’ Comp Reform and the Bottom Line: The More Things Change, the More They Stay the Same
In its official summary of Public Act No. 97-0018, the Illinois Workers’ Compensation Commission describes the new law that went into effect in Illinois on June 28, 2011 as “significant Workers’ Compensation reform legislation” [see http://www.iwcc.il.gov/summary2011.pdf]. But does the revised statute actually herald reform? And if so, does that reform go far enough to qualify as significant?
To get a sense of the impact that the 2011 legislation has had on workers’ compensation in Illinois from a claims-handling perspective, there is no better person to ask than industry thought leader Mark Walls, the Assistant Vice President of Claims at Safety National. Walls is an expert’s expert—he knows the ins and outs of workers’ compensation from a practical, business sense and can cut through the dense language of a statute to understand and explain how its provisions will affect the bottom line. Plus, as a seasoned veteran with decades of field experience participating in TPA audits around the country, Walls has an innate sense of which statutory provisions might be real cost savers, and which items will be premium neutral.
In the following interview comments, Walls shares his views about
Walls also discusses how attempts at workers' compensation reform are affected by the nation's economy and gazes into his crytal ball in an effort to explain the steps that he believes will guide the industry in the direction of true reform.
Utilization Review – Show Me Your Teeth
Utilization Review is nothing new in Illinois. The industry saw it in prior reform legislation passed in 2006, and according to Walls, “[a]t that time it was supposed to help decrease costs. It didn’t. It wasn’t applied well. It was not utilized sufficiently.” And, although the new legislation allows for a greater reliance on UR, and even threatens providers that drag their feet on compliance with the possibility of non-payment, Utilization Review in Illinois continues to include a layer of judicial review.
”The bottom line with utilization review is that it ends up in the courts. It's not like you get a UR decision, and they say ‘no,’ and that's the end of it. What happens next is that you go to the courts. And then you have the judges making utilization decisions. It puts you right back where you began, and that's why it didn't work initially. When people tried it, the UR decisions were never being upheld by the court. Now they roll out this new law and say, ‘but this is better UR this time,’ for whatever reason, but to me it's the same animal. It's still UR, it still loops through the court, so ultimately it's the judges making the decisions.”
Walls nevertheless believes that UR can work—if the system has teeth—and this means replacing courts and judges with some type of an alternative dispute resolution that involves individuals with a medical background.
“Frankly, in states where I have seen UR work well, it's handled outside of the courts. They have a medical review panel, so to speak, where you have medical professionals reviewing medical determinations, not judges. That's the big flaw with any UR system that's set up, that the dispute resolution goes to the courts. You end up with judges making decisions on whether or not this person needs surgery. The judge is not trained to know whether or not this person needs the surgery. They're not a physician. Again, you're taking the decision out of the physician's hands, which is the whole point of UR, but then you shove it back into the court. And that is the inherent flaw with the UR process in Workers' Comp."
Walls’s view is clear—UR works best when courts are taken completely out of the loop. As for potential cost reductions under the new (albeit multi-tiered) UR system in effect in Illinois for treatment provided on or after September 1, 2011, Walls adopts a wait-and-see approach:
“Whether or not it will actually reduce medical costs is something that won't be known until we get a few years down the road and see some claims actually go through the UR process and see the outcome.”
To read the complete interview of Mark Walls, purchase the article here at the LexisNexis Bookstore. (Approx. 14 pages)
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