Determining the type of care for Workers’ Compensation claims
Have you ever been in a situation where you, a co-worker, or an employee is injured or becomes ill on the job and panic settles in, leading to an emergency room (ER) visit for a minor issue? If so, you are not alone. The National Hospital Ambulatory Medical Care Survey estimates that between one-third and half of all ER visits are for non-urgent care. It is estimated that more than $18 billion could be saved annually if patients whose medical problems were not urgent visited a primary care office, urgent care center, or occupational health clinic. Making the right determination on where to get treated can save your organization on costs and improve the chances of a Workers’ Compensation claim being approved.
Think about severity
For an extreme medical condition that is potentially life-threatening, such as chest pain or severe burns, going to the local hospital emergency room is the best choice. An urgent care center is best for a condition that needs to be tended to on the same day that is not life-threatening. Minor conditions that are not potentially life-threatening should be examined at a primary care facility, occupational health clinic, or through a telemedicine visit.
While there could be crossover between minor conditions that justify an urgent care visit, telemedicine visit, or doctor visit, there are symptoms you can look for to help you make this decision.
When to think ER
Consider a trip to the ER for severe conditions, such as a potential heart attack or stroke and severe bleeding that cannot be stopped. Other reasons to go to the ER include severe burns, severe pains, a fever higher than 104 degrees Fahrenheit, paralysis, and/or shortness of breath that persists. An ambulance ride to the ER should be used only for potentially life-threatening situations, such as severe chest pain and loss of consciousness.
What defines a high blood pressure emergency?
High blood pressure, also known as hypertension, is one condition that is often directed to the ER unnecessarily. When someone has high blood pressure, the factor to look for to justify an ER visit is the presence of other immediate symptoms that indicate it could be life-threatening, such as chest pain or shortness of breath.
Learn the difference between a high blood pressure hypertensive urgency and a hypertensive emergency:
- Hypertensive urgency: If your blood pressure is 180/120 or greater, it is recommended to wait approximately five minutes and check again. If the second reading is just as high and you do not have any other symptoms such as chest pain, shortness of breath, back pain, changes in vision or difficulty speaking, an ER visit is likely not warranted. You should seek help from a non-urgent medical provider in this situation. Your medical provider may add or adjust medications.
- Hypertensive emergency: If your blood pressure is reading 180/120 or greater and you are experiencing other symptoms listed above at the same time, it is recommended to either call 9-1-1 or go to the ER.
- Other reasons to see a doctor for high blood pressure: If you have high blood pressure that is less than 180/120, you should contact a clinic, primary care doctor, or urgent care.
Estimated cost range: $2,000-$5,000 for the facility and $300-$500 for the physician; an extra $800-1,500 for a ground ambulance; and $10,000-$45,000 for air ambulance. There may be a separate charge for X-rays and lab testing.
When to think urgent care center
Symptoms appropriate for an urgent care center visit include fevers below 104 degrees Fahrenheit, possible respiratory or urinary infections, bites, sprains, and possible minor broken bones, cuts and bleeding that may require stitching, breathing discomfort, minor burns, and/or minor pains.
Estimated cost range: $300-$500; There may be a separate charge for X-rays and lab testing.
When to think doctor visit or occupational health clinic
Contact a primary care office or occupational health clinic for fevers, flu, cold symptoms, ear infections, animal or insect bites, seasonal allergies, bronchitis, sprains or possible minor broken bones, cuts and bleeding that may require stitching, vomiting, diarrhea, breathing discomfort, urinary tract infections, X-rays or basic lab tests, minor abdominal pain, and minor back or limb pain.
Estimated cost range: $90-400 (for a new condition); There may be a separate charge for X-rays and lab testing.
When to think telemedicine
To avoid travel costs for minor injuries or conditions, telemedicine can be used for Workers’ Compensation medical visits. Conditions that can be treated through telemedicine include bites; slips, trips, and falls; bruises, scrapes, and cuts; skin conditions; minor wounds or burns; cold symptoms; allergy symptoms; and stress.
Estimated cost range: $90-$210; There may be a separate charge for X-rays and lab testing.
Selecting appropriate care can save money
There is some overlap in medical conditions between the options above. Which route you take should factor in medical urgency, additional symptoms, the person’s prior medical history, and costs. While it can be stressful when you or someone at your work is injured or ill, it is very important to remain calm and work through the decision-making process.
In 2018, TASB spent more than $1.5 million on ER visit claims and approximately $883,000 on ambulance costs for Workers’ Compensation claims. In addition to impacting TASB, claims costs can directly impact Fund members as well and is a factor in the cost of contributions or premiums. Treating conditions appropriately can help save your organization these additional costs. For example, if there needs to be immediate care for a potentially life-threatening condition, the ER is appropriate. However, if just same-day care is needed, then an urgent care center is rational. If non-urgent care is needed, an outpatient doctor’s visit or telemedicine visit in an office or a clinic is in order.
Get treated by top-notch providers in network
The Fund is a part of the Subdivision Workers’ Compensation Alliance (Alliance), a partnership of five risk pools. The Alliance maintains a network of high-quality medical providers for injured employees and negotiates rates to provide cost savings to Fund members. As a Fund Workers’ Compensation program member, injured employees have access to these medical providers. However, the Alliance cannot make direct contracts with hospital-based ER or free-standing ER facilities.
This network has been frequently recognized as a high performer in the annual Texas Department of Insurance Network Report Card. Contact the TASB Workers’ Compensation team at 800.482.7276 with questions about your claims.
Dr. Brian Buck is the TASB Medical Director who works in the Workers’ Compensation division, providing medical expertise to support claims decisions.
Tagged: claims, "the Alliance"
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