Date: 08/31/2009
Final
Claimant Attorney
INTERIM COMMITTEE TO STUDY ISSUES RELATED TO PINNACOL ASSURANCE
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10:56 AM -- Claimant Attorney
John M. Connell, an attorney with Franklin D. Azar & Associates, P.C., testified. He has represented inured workers and insurance carriers including Pinnacol. The last four years he has worked on behalf of the injured party side. He discussed issues related to medical care for injured workers. He stated that cost savings are a result/expense of an injured party and affects unrepresented claimants more than represented claimants. An injured worker is allowed a one time change of physician within the list of approved doctors. These are more employer/insurer oriented physicians. Adjusters can talk to physicians. For his clients, he asks that there be no ex parte communications but stated that adjusters and doctors have continued dialogue.
He discussed Pinnacol's employment of nurse case managers (NCM). NCM's may go into a claimant's appointment with a physician and then discuss the case with the physician. This gives the insurance carrier an opportunity to dictate care. Some large employers discuss injured worker cases and include doctors and nurses.
Mr. Connell also discussed impairment ratings and Division Independent Medical Examinations (DIME). Concentra refers to one physician to do impairment ratings which results in cost savings for insurance companies because the impairment ratings for this doctor are lower. With transparency, Pinnacol would be under scrutiny to allow the legislature to monitor what's going on and injured workers would be treated appropriately and given correct impairments ratings. DIME cases generally result in increased ratings.
Mr. Connell pointed out the number of stages in which Pinnacol controls medical treatments for claimants. Pinnacol physician advisors review medical treatments from authorized treating physicians who are already approved by Pinnacol. It is up to the treating physician to push for treatment denied by the physician advisor. He would like Pinnacol to remain a political subdivision of the state so they can be better scrutinized. He likes Pinnacol and says that their claims are well handled. He is concerned that there is too little competition among doctors.
Mr. Johnson, Pinnacol Board Chair and member of the committee, stated that the Pinnacol board hired additional NCMs not as spies but to ensure a physician provides the best care. Their role is to help injured workers. Mr. Connell responded that he understands that's the purpose and that NCM's can be very beneficial. In an average case, the NCM is letting the doctor know what the adjuster feels is necessary. Mr. Connell requests that NCMs not be used for his clients.
Senator Mitchell asked what the response is from Pinnacol when he asks them not to include a NCM. Mr. Connell responded that not by choice in Colorado, a claimant has the right to refuse a NCM.
Dr. Parry asked about physicians as businesses and reaching a balance when competing for business. Mr. Connell spoke to this issue and noted that most clients are treated through Concentra and that complex cases are referred to two specific physicians to close and do the impairment rating.
Representative Miklosi asked about whether Pinnacol steers cases towards physicians who have a high rate of denials. Mr. Connell testified that there are physicians who are more claimant-oriented and others more respondent-oriented. Doctors can make a lot of money testifying on behalf of insurance carriers and he sees the same physicians being called to testify regularly for insurance carriers.
Mr. Simon asked about a link between the size of a claim and the effort of a company to fight it. Mr. Connell doesn't think that is generally the case. The most common occurrence he sees in his practice is denial of request for surgery.
Representative Gardner posed a number of questions about Mr. Connell's practice, his experience with Pinnacol, his compensation and his firm. Mr. Connell works for a plaintiff's firm, Franklin D. Azar and Associates, and receives 20 percent of the settlement for an injured worker. When he worked on the defense side, he was paid by the hour by insurance carriers. He would receive no payment for medical benefit awards. Mr. Connell talked about differences between Pinnacol and other insurers due primarily to size. Pinnacol has people who focus on return-to-work, their own nurse case managers and physician advisors that other insurers don't have. Liberty Mutual moved their claims office to Texas. Overall size means that for clinics like Concentra, they are a substantial part of their business. Having NCM's physician advisors dictating to doctors is a business practice of Pinnacol but not other carriers. This could be detrimental to injured workers.
Mr. Ross asked Mr. Connell if he was familiar with how many claims are filed with Pinnacol, and the denial rate. Mr. Connell responded that he did not know, but didn't think it was relevant to what he's talking about.