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June 15, 2011 — A pizza delivery guy who gets punched in the mouth during a robbery. A UPS driver who is hit in the face with falling boxes. A farmer kicked by a horse. An amusement park worker playing Spiderman who couldn’t quite stick to the wall.

What do these people have in common? They all experienced workplace-related dental injuries that were covered by workers’ compensation. But finding a dentist to treat them was a challenge for insurance companies handling such claims.

Dentists have shied away from workers’ comp cases because of low reimbursement rates and the complicated claims process. But now there’s a company that works with insurance companies and guarantees payment to dentists while also streamlining the paperwork. And now thousands of dentists across the U.S. have signed up to treat such cases.

“Insurance companies were saying that it’s hard to find dentists who would accept workers’ comp cases,” Stacey Whidden, CEO of Express Dental Care, explained to DrBicuspid.com. “And dentists complained about low reimbursements and the amount of paperwork. It took a lot of convincing because they had bad experiences with workers’ comp.”
“It was miscommunication between both the dentists and the insurance companies.”
— Stacey Whidden, Express Dental Care

The 10-year-old company handled more than 29,000 dental claims last year using 16,000 dentists in its network. The injuries run the gamut: In addition to pizza delivery people who get punched during robberies and farmers who get kicked in the teeth by a skittish animal, Express Dental Care has seen claims for mechanics hit with wrenches, hockey players hit by pucks, baseball players hit by bats or balls, roofers, construction workers, and migrant workers injured by farm equipment or falling branches.

“We’ve had a lot of UPS and FedEx drivers who fell or had boxes hit them in the face,” Whidden said. “The amusement park cases are always funny.”

Express Dental Care connects insurance companies with the dentists in its network, then helps clinically manage the cases.

“We tell dentists what forms to fill out, and we help with the paperwork,” Whidden explained. Each state has different forms, she noted; some, like Florida, change theirs every year.

The company also removes the doubt about reimbursements, confirming in advance just how much dentists will be paid for their services.

“We let them know what the reimbursement will be so they’re guaranteed payment of the procedures approved,” she noted. “We take the risk that the insurance company will pay.”

Some states have workers’ comp fee schedules, but many don’t, Whidden pointed out.

“Many dentists don’t understand workers’ comp,” she said, “so it was miscommunication between both the dentists and the insurance companies.”

How it works

Express Dental Care schedules an appointment with a dentist who does the evaluation and submits a treatment plan that is analyzed to ensure the work will be covered by the insurance company. The company also advises dentists on dental notes that may be required to document the injury and substantiate the claim.

“Dentists want to treat the whole mouth,” Whidden said. “But if the items aren’t related to work injuries, like if they have cavities that are nowhere near the dental trauma, then the worker has to pay for those himself.”

Participating dentists say the referrals have helped build their practices because the patients often become regular clients. And in the current bad economy, many are finding that it’s a way to fill otherwise empty chairs.

Whidden’s company helps insurance companies understand why the same injury can cost different amounts. “They would get an $800 bill for a chipped tooth, then the next day they’d get a $1,500 bill for the same thing, and they didn’t understand why,” Whidden said.

Sometimes dental work is needed before other injuries can be treated. One worker couldn’t have knee surgery because he had an oral infection that had to be cleared up before he could get anesthesia, Whidden recalled.

Other cases require specialists such as endodontists and maxillofacial surgeons, and the company has to explain and justify their treatments. “We have to go back and forth between specialists and explain that you have to wait for bone grafts to heal before putting in implants,” she pointed out.

The cases also differ due to the worker’s prior dental history. “If a young person slips and chips their tooth, it’s simple because they have good bone structure, and they’re usually in good dental health,” Whidden explained. “But if the injured worker hasn’t been to the dentist in 10 years, they may have perio disease, gingivitis, or poor bone structure so it’s not going to be a simple crown. Sometimes it’s so much more that’s needed.”

When migrant workers get hurt, the paperwork gets complicated because they often move from the state where they were injured to other states while following the harvest.

Prices also vary depending on geographic location: Bills will be more in New York City or San Francisco than Des Moines, IA, for example, Whidden said.

“Injured workers just want to be treated and have their mouth restored,” she said, “and they deserve good care.”

ALBANY, NY (WAMC) – As the end of the legislative session draws near, New York lawmakers have approved new protections for student athletes who get concussions. Capital District Bureau Chief Dave Lucas reports.

The new rules require immediately benching those who may have a mild traumatic brain injury and keeping them sidelined from sports or gym classes until they’re symptom-free for at least 24 hours and obtain written authorization from a doctor. Kemp Hannon is a Long Island Republican who chairs the Senate Health Committee, he spearheaded the legislation in the Senate.

He notes the Concussion Management Awareness Act has passed both the Senate and Assembly. The bill’s supporters promise it will “establish minimum guidelines regarding removal from play, physician clearance, and return to play protocols,” – rules affecting New York’s nearly 700 school districts that will be adopted by the state Education Department along with the state Health Department.

Christopher Hobler, President of the New York State Athletic Trainers Association, applauds the measure. But not everyone believes the protections afforded by the new law do enough to protect youth. Michael Kaplan is the chair of the New York State Traumatic Brain Injuries Services Coordinating Council and the past president of the Brain Injury Association of New York State. He says the new law doesn’t go far enough.

Senator Hannon concedes the new measure isn’t perfect, but he’s glad the bill has finally passed: various versions of it have been pending in Albany for five years. It will take effect on July 1 after it is signed into law by Governor Andrew Cuomo.
http://www.publicbroadcasting.net/wamc/news.newsmain/article/1/0/1815880/WAMC.New.York.News/NY.Lawmakers.Pass.Student.Concussion.Rules

NEW YORK (AP) — A Staten Island woman has settled a personal injury lawsuit with NYC Transit for $300,000, her second settlement with the agency in five years.

According to court papers, Lydia Batson suffered neck injuries in July 2006 during a collision on the Verrazano-Narrows Bridge while riding a Manhattan-bound bus.

Her lawyer, Louis Mauriello, tells the Staten Island Advance that the injuries exacerbated a pre-existing condition suffered during another accident in 2003 involving another city bus. He says she filed a personal-injury lawsuit in that case and settled it for about $10,000. He says NYC Transit paid $4,200 and a co-defendant paid the rest.

The Metropolitan Transportation Authority declined to comment on the latest settlement.

Commercial insurance prices remained “relatively flat” overall during the first quarter of 2011, but workers compensation prices showed a modest increase, according to a survey Towers Watson & Co. released Monday.
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The first-quarter rise of about 2% in workers comp pricing comes after two years of relatively flat conditions, Towers Watson said.

“The increases in workers compensation prices this quarter are larger than we’ve seen in quite some time, and package (commercial multiperil and business owner policies) and general liability are also showing upticks,” Bruce Fell, director of Towers Watson’s property/casualty practice in the Americas, said in a statement.

Second-quarter rises expected

“While the overall story is still one of flat prices, the observed movements, coupled with recent weather-related insurance losses that are expected to firm property prices, could mean more significant increases in the second quarter of 2011,” Mr. Fell said.

Workers comp prices already had been increasing in California, but were offset by decreases elsewhere during recent quarters, Towers Watson said. But prices outside of California showed an increase during the first quarter of 2011, the first time in nearly six years, the New York-based consultant said.

Towers Watson said its Commercial Lines Insurance Pricing Survey is based on information contributed by 39 insurance companies representing 20% of the U.S. commercial insurance market.

A highly trained helicopter mechanic sits in her Chattaroy home and wonders what will come next: another debilitating brain seizure or the therapy she hopes will help her recover from injury as a result of a mortar explosion 20 months ago in Afghanistan.

By KEVIN GRAMAN

The Spokesman-Review
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SPOKANE, Wash. —

A highly trained helicopter mechanic sits in her Chattaroy home and wonders what will come next: another debilitating brain seizure or the therapy she hopes will help her recover from injury as a result of a mortar explosion 20 months ago in Afghanistan.

Jennifer Barcklay says she is being denied the specialized inpatient medical treatment her doctors believe is her only hope for a normal life.

“These are war crimes, using taxpayer dollars to profit from injuries incurred by people fighting for our freedom,” Barcklay says.

Although she is a U.S. Army veteran, Barcklay, 40, was injured as a civilian working for Blackwater, the private security contractor now known as Xe Services. She and thousands of other civilian employees injured in the defense of their nation have had to navigate an often unresponsive private insurance system.

Xe’s insurance carrier has so far denied Barcklay expensive inpatient treatment known as cognitive rehabilitation therapy, which was recommend by eight Spokane area physicians and mental health care providers.

She suffers from traumatic brain injury, the signature wound of the Iraq and Afghanistan wars, for which thousands of U.S. soldiers are receiving care in military or Department of Veterans Affairs facilities. Like many of them, she continues to endure seizures, memory loss, headaches, tremors and problems with her balance that prevent her from returning to work.

Under the Defense Base Act of 1941, defense contractors must provide medical and disability insurance for their workers in war zones. The premiums are included in the companies’ contract with the Department of Defense.

There have been nearly 56,000 such claims for injuries or deaths from the start of the Iraq war to 2009. That year, a congressional investigation found that insurance companies had collected $1.5?billion in premiums, while they paid out about $900?million in compensation and expenses.

Another World War II-era law, the War Hazards Compensation Act, reimburses the employer or insurer for injuries or death to a worker caused by an act of war. The insurer is reimbursed by the taxpayers for 100 percent of the claim, plus 15 percent for administrative costs. From 2003 to 2010, the federal government paid more to insurers for expenses, $19.7?million, than it paid in compensation, $12.1?million, to claimants under the act.

More than three-quarters of the Defense Base Act claims were handled by American International Group, which was rescued in 2008 by the U.S. government in the largest corporate bailout in history.

An AIG subsidiary, Insurance Company of the State of Pennsylvania-Chartis WorldSource, took months to authorize a neurological evaluation for Barcklay. Now Chartis is refusing to pay for her inpatient treatment.

“Frankly, I am appalled at how many obstacles have been placed in the way of her receiving the treatment she needs,” Spokane neuropsychologist Winifred Daisley wrote in a December letter to Chartis case manager Debra Ragan.

Marie Ali, a Chartis spokeswoman, said she could not comment on individual claims but that the company “is committed to handling every claim professionally, ethically and fairly.”

“We provide the highest level of service to our insureds, which includes the prompt adjudication and payment of claims.”

A spokesman for Xe Services said, “The company has worked diligently with the insurance provider to help ensure Ms. Barcklay receives the level of care and treatment she needs.”

Barcklay, a 1989 graduate of Lewis and Clark High School, studied art and archaeology at Evergreen State College and became an accomplished artist. Despite selling her oil paintings at galleries in Seattle and New York, she found it difficult to pay her student loans and joined the Army in April 1994.

At Fort Campbell, Ky., she learned to repair UH-60 Blackhawk helicopters before injuring her knee in jump school; she was honorably discharged in October 1996.

Despite her small frame, she became a certified firefighter and emergency medical technician before returning to school to become an airframe and aircraft power train mechanic specializing in remote mountain recovery of helicopters.

She worked for the defense contractor L-3 Vertex Aerospace in Iraq from 2006 to 2008. Then she joined Blackwater subsidiary Presidential Airways, repairing military and civilian helicopters in Afghanistan in 2009. Xe Services sold Presidential Airways in March 2010.

In September 2009, while working at Forward Operating Base Shank in eastern Afghanistan, Barcklay was returning from lunch in the mess tent when an enemy mortar exploded 10 yards from her as she passed an opening in the blast wall.

“It was like every joint in my body separated and then slammed back together,” Barcklay said.

The force of the blast threw her to the ground. A forklift operator and a soldier also were severely injured by the explosion.

“I remember being on the ground, but I don’t remember falling,” Barcklay said. “I saw the smoke cloud, but I couldn’t hear anything. I couldn’t stop shaking.”

She was treated at a nearby Army base for ear trauma and joint pain and returned to the United States in November 2009. She returned to Afghanistan in early January and continued working for about a month despite reporting vertigo and shakiness, headaches, tinnitus and blurred vision.

When she came home to Spokane in February 2010, Barcklay began seeing medical providers for continued problems with seizures, pain, hearing, balance and memory loss.

In March last year, Dr. Neil Giddings, an ear, nose and throat specialist, recommended cognitive testing and rehabilitation. Upon completing the evaluation in July 2010, neuropsychologist Daisley diagnosed “post-concussion syndrome caused by blast injury” and recommended comprehensive cognitive rehabilitation.

According to Barcklay’s medical records, this recommendation has been supported by Giddings, as well as Dr. Madeline Geraghty, medical director of the neurology department at Providence Sacred Heart Medical Center; Dr. David Ramey, of Kootenai Neurology; Dr. Karen Stanek, brain injury psychiatrist at Northwest Medical Rehabilitation; Dr. Heidi Heller, neurologist, and Dr. Daniel Hesskamp, internal medicine specialist, of the Spokane Veterans Affairs Medical Center; and Dr. Rod Peterson, psychiatrist, Spokane Psychiatric Clinic.

“I do not believe her symptoms have a psychiatric causality – this is a neurological problem directly due to blast injury,” Daisley wrote.

Peterson, who met with Barcklay six times, wrote, “I do not believe her seizures are caused by a psychiatric condition.”

Through an independent contractor, Chartis hired a nurse, Theresa Trimmell of Northwest Medical Management, to coordinate Barcklay’s case. After consulting with the specialists, Trimmell researched the options available to her patient.

After determining that there was no appropriate rehabilitative program in Washington, Trimmell contacted the Centre for Neuro Skills in Bakersfield, Calif., which evaluated Barcklay and accepted her for treatment.

Upon submitting her work with Barcklay to Chartis in October 2010, Trimmell’s contract was terminated unexpectedly.

“When I first saw (Barcklay) she had a caseworker with the insurance company who seemed really supportive and seemed like she was going to make things happen, and then she was taken off the case,” Daisley said.

It has been nearly a year since the neuropsychologist recommended cognitive rehabilitation, which is more effective the sooner it is given.

Injured defense workers often have to battle insurance companies that routinely deny medical benefits, causing long delays in treatment, the House Committee on Oversight and Government Reform discovered in 2009.

On April 22, Barcklay’s attorney, David M. Linker, met with Chartis’ attorney, Michael W. Thomas, in a Department of Labor Office of Workers’ Compensation conference. Thomas said Chartis was waiting for an independent review of Barcklay’s medical records.

The review by Dr. W. Curt LaFrance Jr., director of neuropsychiatry and behavioral neurology at Rhode Island Hospital and assistant professor at Brown Medical School, came on May 20.

LaFrance’s primary diagnosis: “Conversion disorder” accompanied by “adjustment disorder with anxious mood.”

Without examining Barcklay, LaFrance determined that her condition was largely a mental condition characterized by physical symptoms. He wrote that he did not see a need for inpatient rehabilitation.

In response, Peterson wrote a letter to Barcklay’s attorney, rebutting Chartis’ independent review and calling for “a more complete evaluation at an institution such as the Centre for Neuro Skills.” In addition, the Spokane psychiatrist wrote, “The American Psychiatric Association has a very specific and rigid stance against psychiatrists rendering diagnoses on patients they have not examined.”

Mark Ashley, chairman emeritus of the Brain Injury Association of America and CEO of the Centre for Neuro Skills, also reviewed Barcklay’s records.

“Unfortunately, if we continue to try to treat (Barcklay’s) condition in this fragmented way, the likelihood of her improving is low,” Ashley said. “It requires a comprehensive and intensive sort of intervention.”

Ashley denounced the insurer’s reluctance to cover treatment in his facility and attempt to debunk the collective work of her medical providers through “utilization review.”

“It’s unconscionable that they would be this dispassionate while this human being is undergoing such incredible physical and psychological suffering,” he said.

“These people know the difference between right and wrong, and they simply don’t care,” Ashley continued. “They are playing a game with this woman’s life.”

Barcklay said federal law guaranteed that she would be taken care of if she risked her life in a war zone. Now that she is injured she shouldn’t have to fight for treatment, she said, but she will.

“Every night I go to sleep I don’t know whether I will have a seizure or whether I will wake up at all,” she said.