Many employers believe that only metropolitan employers experience the elaborate strategies and comp models designed to short-circuit the workers’ compensation process, like those things that are the subjects of a 20/20 investigative report. The reality is that these same insidious challenges also occur in our own Tri-County Area.

Consider the following hypothetical scenario: An employee believes he has carpal tunnel syndrome. After seeing his family physician, he decides a free consultation with the attorney from one of those all-too-common workers’ compensation commercials is necessary. Upon entering that all-important first visit, he is convinced by his new legal counsel that he needs a surgical consultation. Fortunately, his new attorney knows the “right” surgeon. The surgeon evaluates the worker and sure enough, surgery is “necessary.” Incidentally, the surgeon is not local, nor does he operate locally. Rather, in order to have the surgery done “properly and efficiently,” the attorney arranges an all-expenses paid limousine ride to and from the metropolitan hospital of the surgeon’s choice, where the surgeon does have privileges (and ironically, is a stone’s throw from his home).

One additional detail: The surgeon bills the surgery at a rate far exceeding the set Illinois fee schedule. Why? If the surgery is denied as a comp case, the surgeon stands to gain more reimbursement for the surgery than if it is capped by the comp fee schedule. To complicate this hypothetical case even more, since geographic location determines the comp fee schedule, a metropolitan-area surgery is likely more costly from the start. Higher medical costs generally translate into larger non-medical settlement fees for both the attorney and worker.

Does it happen in central Illinois? You bet it does. As we speak, there are surgeons and attorneys teaming up to bring this new show to town. How does this affect the employer? It creates increased medical and case management costs, increased legal fees (if any were needed at all), increased travel costs and increased potential for problematic outcomes due to that travel.

Here are a few red flags to look for when you’re seated as an unwitting audience member of this show:

  1. Is there a rapid progression to employee representation?
  2. Has your worker stated that his attorney believes he should have diagnostic tests or see a specialist that the attorney has recommended?
  3. Is the specialist local, not only in reputation, but also in residence and practice?
  4. Does the specialist have an office located in close proximity to the attorney? 
  5. Are the worker and his attorney requesting travel out of the area for treatment that is routinely and competently offered locally in the Tri-County Area? 

If any of these flags come up, it is up to you to be vigilant in contacting your insurance representative and making them aware of the potential circumstances. iBi