The Bottom Line for Subrogation: Patients Come First

By: | August 13, 2019

Kevin Turner is a leader in workers’ compensation and claims management, with over 30 years of experience in the industry. As the Chief Executive Officer of Paradigm’s Catastrophic Care Management division, Kevin oversees the industry-leading provider of services for workers with the most challenging and expensive catastrophic injuries. Kevin can be reached at [email protected]

A recent Claims Journal opinion piece cited a legal case Paradigm was involved in (Ocampo v. Paper Converting Mach. Co) to highlight subrogation issues.

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The piece is misleading, because it focuses solely on subrogation without embracing the larger picture. Like the parable of the blind men and the elephant, it draws broad implications based on an incredibly narrow point of view. Let’s take a look at the larger issues to set the record straight.

When discussing law, it’s easy to get lost in the arcane issues and forget that cases are really about people.

In Ocampo, the person — the patient — had severe catastrophic injuries, which threatened his life, livelihood and family. Before we dive into subrogation, let me point out that this man recovered from his injuries. In fact, he had the best possible outcome in one of the most complex cases Paradigm has ever encountered. No matter how you slice it, that is the most important result. We wish Claims Journal had mentioned it.

Now, let’s talk about subrogation. Paradigm takes cases (and risk) at a fixed price, which includes all medical costs from the injury date until the final outcome.

This financial certainty is unique in the industry, which is why carriers opt into our outcome plan contracts. Paradigm brings together a multidisciplinary team of clinicians and other experts to ensure each injured worker gets outstanding care. This approach keeps patients on track, minimizes avoidable medical complications and delivers the best outcomes for injured workers, providers and carriers.

The Claims Journal piece cautions insurers that the price paid for the outcome plan contract, which includes medical payments, may not be recoverable in a third-party action. The piece also tries to describe how the contract works and why insurance carriers and employers engage Paradigm. It also opines on state regulatory involvement and carrier intent, saying they simply “abdicate,” which is both loaded terminology and factually inaccurate.

The industry engages Paradigm to manage the most catastrophic cases, because we guarantee excellent functional outcomes for injured workers. We do this by approaching the injury as holistically as possible. To heal the injured worker, we address their physical injuries, as well as the emotional trauma that hits them, their families and their communities.

Our clients pay a premium to engage Paradigm in these rare catastrophic cases. They recognize the value of our expertise — providing outstanding functional recoveries and putting the pieces back together after a horrific, life-changing event.

Insurance carriers don’t “abdicate,” they engage from start to finish. They collaborate with Paradigm on all plans before signing off and monitor each patient’s progress throughout their journey.

The piece treats subrogation and the Paradigm contract as if it’s a newly discovered issue. But in fact, Paradigm clients (carriers and employers) fully understand the subrogation rules and their potential inability to recover expenses.

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These are incredibly smart people, and they knowingly make these choices because they recognize the value Paradigm’s services bring to patients and all stakeholders. No one is signing a contract without complete information.

The Claims Journal piece also implies that Paradigm may be somehow shorting patients. This is both incorrect and dangerous. It’s incorrect because we have years of excellent outcomes, and we’re happy to produce the evidence from Milliman and others to prove it.

It’s dangerous because it skews people’s opinions based on faulty information. Soon after the article was published, one of our clients reported that, shortly into horrible, life-changing events, two families declined Paradigm’s services. We believe they may have seen the Claims Journal accusations on social media. Narrow and inaccurate opinions can have real, and in this case, traumatic consequences.

Subrogation is an important topic that should be discussed, but it shouldn’t be presented in an isolated, misleading way. We can resolve these kinds of legal issues based on the facts, state law and other factors. What we cannot do is forget the workers who need catastrophic care. At Paradigm, we will not allow these good people to be injured twice. &

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The R&I Editorial Team can be reached at [email protected]